What questions would you like addressed during this evaluation?

* Child's Name:

• First
• Last (surname)

* Parent/guardian Name:

• First (given name)
• Last (surname / family name)

* Address:

• Street
• City
• AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY State
• Zip Code

Home Phone:

Cell Phone:

Email address:

Date of Birth:

Medical Diagnosis:

Educational Diagnosis:

Physician's Name:

Physician's Address:

• Street
• City
• AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY State
• Zip Code

Physician's Phone:

Language(s) spoken in home:

School Name:

Grade (please select) Pre-K K 1 2 3 4 5 6 7 8 9 10 11 12 other

School Address:

• Street
• City
• AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY State
• Zip Code

School Contact Name:

School Contact Phone:

Speech Diagnosis:

Onset of Medical Condition/Diagnosis:

If yes, type and frequency:

If not, how does the child move around?

Date of last screening:

Date of last screening:

Describe any other significant concerns:

Does the child have any motor movement challenges?

• Yes
• No
• Don't Know

If so, please describe:

Holds head steady?

• Independent
• Requires Support
• Unable

Walk?

• Independent
• Requires Support
• Unable

Feeds self?

• Independent
• Requires Support
• Unable

Isolates finger and points?

• Independent
• Requires Support
• Unable

Handedness:

• Left
• Right
• Don't Know

Child can use:

• Both Hands
• One Hand (R or L)
• Neither Hand

Please list any special equipment used for gross or fine motor activities:

Approximately how intelligible is the child to unfamiliar listeners?

Approximately how intelligible is the child to familiar listeners?

If yes, how?

Forms of communication used by child (please check all that apply and list examples of each):

If child uses pictures, what format?

• Isolated Pictures
• Communication Board
• Communication Book

Has an augmentative and alternative evaluation ever been completed in the past?

• Yes
• No

If yes, please provide name and contact info for evaluator:

Name:

Phone:

Email:

Date of Evaluation:

Has any type of augmentative or alternative communication been used or recommended in the past?

• Yes
• No

If yes, what?

What is the child's primary mode of communication at home?

What is the child's primary mode of communication at school?

Responds to speaker:

• Regularly
• Sometimes
• Never

Understands what is said to him/her:

• Regularly
• Sometimes
• Never

Follows simple directions:

• Regularly
• Sometimes
• Never

Follows complex, multi-step directions:

• Regularly
• Sometimes
• Never

Can group similar items together (e.g. clothes, food):

• Yes
• No

Does the child understand more than he/she is able to communicate?

• Yes
• No

Identifies numbers?

• Yes
• No

Identifies colors?

• Yes
• No

Identifies shapes?

• Yes
• No

Identifies letters?

• Yes
• No

Describe child's reading skills:

What are the current therapy goals for the child?

What are the most important communication needs at home?

What are the most important communication needs in school/community?

Please list services your child is currently receiving.

Speech

Start Date:

Frequency:

Therapist:

Location:

Phone:

Email:

Goals:

Occupational Therapy

Start Date:

Frequency:

Therapist:

Location:

Phone:

Email:

Goals:

Physical Therapy

Start Date:

Frequency:

Therapist:

Location:

Phone:

Email:

Goals:

Other

Start Date:

Frequency:

Therapist:

Location:

Phone:

Email:

Goals:

What are some of your child's favorite things or activities? (examples include specific foods, music, people, activities, toys, games, places, etc)

Please describe any behaviors you feel might be significant for this evaluation:

Please estimate attending skills for structured tasks:

Please include any additional information you feel would be helpful: