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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?
Vaginal Delivery
Vaginal Delivery
C-Section
Forceps
Breech
Other Complications
Premature
Jaundice
Colic
Birth Defects
Breathing Problems
Feeding Problems
Sleeping Problems
Substance Exposed
Nicotine Exposed
Breast Fed
Bottle Fed
Special Formula
Vaginal Delivery
C-Section
Forceps
Breech
Other Complications
Premature
Jaundice
Colic
Birth Defects
Breathing Problems
Feeding Problems
Sleeping Problems
Substance Exposed
Nicotine Exposed
Breast Fed
Bottle Fed
Special Formula
Developmental Milestones
Place the age child met developmental milestone:
First Steps
Spoke single words
Fully toilet trained
Identified colors
Walked without help
Identified letters
Spoke in phrases
Medical History
Check all that apply:
Balance Problems
Emotional Problems
High Fevers
Medication
Mental Illness
Convulsions
Ear Infections
Memory Difficulties
Head Injuries
Seizures
Allergies
Vision Difficulties
Diabetes
Glasses
Stomach Problems
Accidents
Asthma
Frequent Headaches
Social/Emotional Development
Check all that apply:
Happy Child
Demands excessive attention
Overly dependent on others
Wets bed
Plays well with other children
Plays well with other children
Tries to control others
Lacks motivation
Compulsive with order
Overly anxious to please
Poor self-control
Lazy
Fearful
Exhibits uncooperative attitude
Limited friends
Aggressive
Shy, withdrawn
Moody
Friendly
Sad
Easily frustrated
Acts younger than age
Affectionate to family
Daydreams often
Restless
false
Jealous
School Information
Check all that apply:
School Information
Special Education (IEP)
Early Intervention Services (EIP with SST)
Enrichment or Discovery Program
Academic Difficulties
Undesired Conduct
Scholarships
Retention of Grade(s)
Lack of School Support with Staff
Placement Assessments
Short Attention Span
College Planning
Counseling
Social Studies
Reading
Math
ELA
Grades
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