Once you have scheduled an appointment, please review and respond to the following two sections. First, please bring the answers to the following list of questions to the initial meeting.

You may elect to email the answers instead. Email: smuir@testingld.com

Second, parents and/or students are asked to consider the posted requests that follow. Please bring the listed documents and other relevant items on the day of testing.



Please respond to the following questions:

1.  List name of student, age, date of birth.

2.  Family. List immediate family members living in/out the home currently. List siblings and ages. List parents’ names. With whom does the student live?  If separated or divorced list dates and if applicable names of stepparents, step-siblings or half-siblings, cities/states of residence as well. Describe frequency and duration of visitation. If raised by guardian other than parent please state relationship/dates/terms.

3.  Contact information. Please list current mailing address, preferred email for parent/s, email of student (if applicable), phone number, mobile number of parents and student (if applicable).

4.  Addresses. List all cities/towns student has lived and dates of residence.

5.  Native tongue. English speaking home? Are there any other languages othr than English spoken in your home? Dual language home?

6.  Pregnancy/birth. Fullterm pregnancy? Mother have any accidents, illnesses or any other unusual conditions during pregnancy?If yes, please explain.  Any complications to mother or child at birth? If yes, please explain.

7.  Adopted? If so, at what age? Any other relevant information.

8.  Developmental history. Expressive language (e.g. utterances, words, sentences) on time, earlier or later? Physical milestones (e.g. standing, crawling, or walking) on time, earlier, or later?

9.  Vision and hearing. Recent exams? Typical? Glasses/Contact lenses? Near/far sighted? Surgeries? History of ear infections? Tubes? Tonsils out? Adnoids out? Dates. hearing loss? Hearing aid? Explain. Last appointments.

10.  Hobbies student is interested? How student spends time after school? Summer?

11.  List all school placements beginning in preschool through current. Dates included.

12.  Any previous learning disabilities or attention deficit disorder previously diagnosed?  If yes,  diagnosis/es?  By whom?  Year?

13. What is the student's overall physical health? List of all medical doctors, cities/states, and description of any childhood illnesses, conditions, injuries (including head/concussion injuries), seizures or hospitalizations, any diagnosis/dates if applicable.

14. Allergies? If so, explain.

15.  List of all medications prescribed in past/current and dates.

16.  List of all speech and language, occupational, vision and psychological therapy: names of providers and dates of service.

17.  Any documented or suspected history in the family of learning disorders, anxiety or mood disorders, or attention deficits. If so, what is the relationship to the student?

18. If applicable list job history (employer, position, dates of employment)

19. History of tutoring? Subjects, tutor name/agency, dates. Effective?

20. Primary presenting challenge? reading (comprehension, fluency/speed, decoding/souding out words), math (calculation, concept, speed), writing (organization, execution, grammar, spelling, speed), oral language (listening comprehension, oral expression), attention (focus, concentration, impulsivity)?  

21. Potty-training. Early typical late? Bed wetting? Explain.

22. Eating. Typical? Picky? Colic as baby? Eating disorders? Digestive conditions (e.g. colitis) ? Overweight? Any recent changes in appetite? Any digestive issues? Stomach aches? Chronic constipation/wtihholding or soiling?

23.  Sleeping. Easy typical difficult falling asleep and waking? Explain. How soundly does your child sleep? Hours each night of sleep?

24. Legal. Any prior arrests? Convictions? Sentencing? Explain. Dates.

25. Words to decribe this student's temperament?

26. What are child's strengths?

25.  Goal of this evaluation.

26. Ability to initiate and maintain friendships with peers and adults?

27. Any recent changes in family life (e.g. new baby, a divorce, a move to new home etc.)?

28. Any other concerns or considerations that would be helpful for the examiner to know and understand.

29.  Referral source:  Contact person, organization, website or other.



On the day of the testing appointment:

1. Please bring lunch, snacks and beverages for the student.

2. Bring recent school records including report cards, and 504Plan/IEPs if applicable, standardized testing results (e.g. SOL, State/County achievement testing, PSAT, ACT). This examiner would prefer comprehensive file dating as far back as possible. All records will be returned.

3. It is recommended that the student consider not taking ADHD medication on the day of this evaluation. The parent/student may wish to consult with their medical doctor as well for further advice.

4. Parents and/or students should be prepared to pay for services on the initial meeting. Credit cards (Master Card, Visa), cash, Cashier's Check, and personal checks are accepted.

5.  If parents are bringing their child to the appointment, please expect to stay with your child for the first thirty to sixty minutes for intake and to complete additional rating scales.

6. The McLean office parking lot is a little tricky to negotiate. Here are specific directions to the office. From Chain Bridge Road, turn into the McLean Professional Park. (Approximate to Giant Food, BBT Bank, Total Wine.)

You will see a HUGE red sign announcing office complex. Continue straight through the complex.  Office is located in building at rear of parking lot. Numbers on side of building "1489." Brick building with white shutters.

Park your car. Travel, walking up the path into the courtyard. Office is second door on right. Brown door. Suite 203. Sign reads "Chain Bridge Psychological Services." Once inside, office door is on first floor, left. Comfortable waiting room.