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Educational Advocacy Customized Tutoring Home Behavior Management Intervention
Print Rich Infused Home Educational Planning *Diagnostic Educational Assessments
*Information in this document is protected by HIPAA privacy laws and should be handled accordingly.
Application
Home Address
Work Address
Background Information
Child Resides With:
Level of Education: GED, High School Diploma, Graduate, or Post Graduate
Level of Education: GED, High School Diploma, Graduate, or Post Graduate
Names of Sibling(s): (Full, Half and Step)
Names of Sibling(s): (Full, Half and Step)
Pregnancy, Birth, & Early Development
Pregnancy, Birth, & Early Development
Was the birth full term?
Was the birth full term?
Check all that apply:
Check all that apply:
Check all that apply:
Was mother under doctor's care?
Developmental Milestones
Place the age child met developmental milestone:
Medical History
Check all that apply:
Balance Problems
Emotional Problems
High Fevers
Medication
Mental Illness
Convulsions
Ear Infections
Head Injuries
Seizures
Allergies
Vision Difficulties
Diabetes
Glasses
Accidents
Asthma
Frequent Headaches
Social/Emotional Development
Check all that apply:
Happy Child
Demands excessive attention
Overly dependent on others
Wets bed
