• Parent Observations of a Child

  • Name of your provider:*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Preferred Contact Method*

  • Personal Information

  • My child's sex is
  • My relationship to this child is:

  • Please provide information for child's family members.

  • Struggled with Learning?
  • Struggled with Learning?
  • Struggled with Learning?
  • Struggled with Learning?
  • Struggled with Learning?
  • Struggled with Learning?
  • Struggled with Learning?

  • My Child's Physical Health

  • (PH1) Is your child in poor physical health?*
  • (PH2) Is your child taking any prescription medications?*
  • (PH3) Does your child have asthma?*
  • (PH4) Does your child suffer from frequent headaches?*
  • (PH5) Does your child have environmental allergies?*
  • (PH6) Has your child experienced seizures in the past?*
  • (PH7) Is your child experiencing seizures currently?*
  • (PH8) Does your child have bed wetting problems?*

  • About Your Child's Diet

  • (D1) Does your child have any food allergies?*
  • (D2) Does your child have any food intolerances?*
  • (D3) Does your child's behavior change when eating high sugar foods?*
  • (D4) Does your child's behavior change when drinking milk?*
  • (D5) Does your child's behavior change when eating foods containing wheat?*
  • (D6) Is your child affected by food coloring or additives?*

  • About Your Child's Hearing

  • (H1)Has your child had a hearing test in the last 24 months?*
  • (H2) Has your child had re-occurring ear infections?*
  • (H3) Has your child had tubes inserted in their ears?*
  • (H4) Has your child experienced ringing in their ears?*
  • (H5) Are you aware of any current hearing problems for your child?*
  • (H6) Is your child's hearing over-sensitive? (sounds are too loud)?*

  • About Your Child's Vision

  • (V1) Has your child's most recent eye exam indicated a need for correction?*
  • (V2) Does your child have a perscription for corrective lenses?*
  • (V3) Is your child willing to use glasses or contacts?*
  • (V4) Concerning your child, are you aware of any current vision problems?*
  • (V5) Has your child been tested for eye tracking, teaming, or movement issues?*
  • (V6) Does your child use colored overlays or classes with colored lenses?*

  • Your Child's Educational Diagnostics

  • (ED1) Has your child had a psychological evaluation?*
  • (ED2) Has your child been diagnosed with an emotional disorder?*
  • (ED3) Has your child been diagnosed with a specific learning issue?*
  • (ED4) Has your child been diagnosed with a specific attention issue?*
  • (ED5) Has your child received an evaluation from a school psychologist?*
  • (ED6) Has your child been referred to Special Education classes in school?*

  • Your Child's Development

  • (D1) Was your child adopted?*
  • (D2) Is your child a foster child?*
  • (D3) Did your child's birth mother have a stressful pregnancy?*
  • (D4) Did your child's birth mother have complications during delivery?*
  • (D5) Was your child separated from his/her mother at birth for hospitalization?*
  • (D6) Has your child had brain injury or concussions?*
  • (D7) Has your child had frightening experiences - real or imagined?*
  • (D8) Has your child experienced emotional trauma?*
  • (D9) Was your child's motor development delayed?*
  • (D10) Is your child overly sensitive to certain items of clothing?*

  • Your Child's Motor Skills and Experience

  • (MS1) Does your child have poor balance?*
  • (MS2) Does your child have poor posture?*
  • (MS3) Does your child experience uncoordinated body movements?*
  • (MS4) Is your child fidgety?*
  • (MS5) Does your child often experience clumsiness?*
  • (AS8) Does your child have difficulty remembering information under time pressures?*
  • (MS6) Are your child's athletic skills poor?*
  • (MS7) Does your child have a poor sense of rhythm?*
  • (MS8) Does your child write or draw using either hand without preference (ambidextrous)?*
  • (MS9) Does your child experience confusion between the directions of left and right?*
  • (MS10) Is your child confused by direction and location?*
  • (MS11) Does your child have difficulty with organization and structure?*
  • (MS12) Does your child experience poor eye - hand coordination?*
  • (MS13) Is your child's hand writing and/or printing illegible?*
  • (MS14) Is your child overly sensitive to touch?*

  • Your Child's Academic Skills

  • (AS1) Does your child have difficulty with attention and focus?*
  • (AS2) Does your child have difficulty completing tasks without prompting?*
  • (AS3) Does your child have difficulty spelling?*
  • (AS4) Does your child have difficulty reading age appropriate material?*
  • (AS5) Does your child have difficulty comprehending what he/she reads?*
  • (AS6) Does your child have difficulty with math?*
  • (AS7) Does your child have difficulty writing his/her thoughts on paper?*

  • Your Child's Emotional Responses

  • (ER1) Is your child afraid of being away from loved ones?*
  • (ER2) Does your child have difficulty keeping his/her temper?*
  • (ER3) Is your child often sad?*
  • (ER4) Is your child easily angered?*
  • (ER5) Does your child suppress his/her true feelings often?*
  • (ER6) Does your child have temper tantrums?*

  • Your Child's Behavior Responses

  • (BR1) Does your child have low frustration tolerance?*
  • (BR2) Does your child have low self-confidence or self-image?*
  • (BR3) Is your child often tense and anxious?*
  • (BR4) Does your child avoid or withdraw from social interactions?*
  • (BR5) Does your child have difficulty setting goals?*
  • (BR6) Does your child have difficulty beginning or completing projects?*
  • (BR7) Does your child have difficulty with time concepts and punctuality?*
  • (BR8) Does your child have a limited sense of aliveness?*
  • (BR9) Is it hard for your child to tolerate stress?*
  • (BR10) Does your child act immaturely?*
  • (BR11) Is your child hesitant to accept responsibility?*
  • (BR12) Is it difficult for your child to make judgments and generalize to new situations?*
  • (BR13) Is completing projects and assignments hard for your child?*

  • Your Child's Social Skills

  • (SS1) Is it difficult for your child to make friends?*
  • (SS2) Is it difficult for your child to keep friends?*
  • (SS3) Is it difficult for your child to interact with close friends?*
  • (SS4) Is it difficult for your child to interact with siblings?*
  • (SS5) Was/is it difficult for your child to interact with teachers?*
  • (SS6) Is it difficult for your child to interact with peer groups?*
  • (SS7) Is it difficult for your child to interact with other children?*
  • (SS8) Is it difficult for your child to interact with adults?*
  • (SS9) Is it difficult for your child to share items with others?*
  • (SS10) Is it difficult for your child to share personal space?*
  • (SS11) Is it difficult for your child to make judgments and generalize to new situations?*
  • (SS12) Is it difficult for your child to share leadership?*
  • (SS13) Is your child inordinately tired at the end of the day?*
  • (SS14) Does your child experience low motivation?*
  • (SS15) Is it hard for your child to be tactful?*
  • (SS16) Is your child shy?*
  • (SS17) Is your child reclusive?*

  • Your Child's Reading Experiences

  • (RE1) Does your child skip lines when reading?*
  • (RE2) Does your child lose his/her place when reading?*
  • (RE3) Does your child skip words when reading?*
  • (RE4) Does your child omit words when reading?*
  • (RE5) Does your child insert words when reading?*
  • (RE6) Does your child re-read words?*
  • (RE7) Does your child substitute words when reading?*
  • (RE8) Does your child insert words or letters from the line above or below when reading?*
  • (RE9) Does your child read the beginning of the words and make up the ending?*
  • (EH1) Is it difficult for your child to stay on the lines when writing?*
  • (RE10) Does your child read the middle of words and make up the beginning or ending?*
  • (RE11) Does your child read the endings of words and make up the beginning?*
  • (RE12) Does your child read slowly, choppily, and unevenly?*
  • (RE13) Does your child struggle more with words the longer they read?*
  • (RE14) Does your child have trouble remembering what was just read?*

  • Your Child's Eye Teaming Skills

  • (ET1) Does your child put his/her elbows on the table or cover one eye when reading?*
  • (ET2) Does your child have difficulty lining up numbers in columns?*
  • (ET3) Does your child experience words doubling when reading?*
  • (ET4) Does your child experience lines doubling when reading?*
  • (ET5) Does your child tilt his/her head to one side when reading?*
  • (ET6) Does your child squint or close one eye when reading?*
  • (ET7) Does your child experience words moving on the page when reading?*

  • Your Child's Eye-Hand Coordination

  • (EH2) Does your child need to use hands or fingers to measure space when writing?*
  • (EH3) Does your child have trouble telling their left hand from their right hand?*
  • (EH4) Does your child have difficulty catching, hitting, or throwing a ball?*
  • (EH5) Does your child have difficulty typing on a computer?*

  • Your Child's Reading Behaviors - Experiences

  • (RBe1) Does your child have difficulty finding hidden figures in a drawing?*
  • (RBe2) Does your child reverse words like "was" and "saw"?*
  • (RBe3) Does your child know a word on one page and then not recognize it on another page?*
  • (RBe4) Does your child move his/her lips or whisper the words to his/her self when reading silently?*
  • (RBe5) Does your child reverse letters or words when copying?*
  • (RBe6) Does your child draw letters like "b" and "d" with fingers to try and figure them out?*
  • (RBe7) Does your child avoid reading when alone?*
  • (RBe8) Does your child avoid reading out loud around others?*
  • (RBe9) Does your child feel uncomfortable when reading?*
  • (RBe10) Is your child restless or easily distracted when reading?*

  • Your Child's Reading Behaviors - Physical Reactions

  • (RBp1) Does your child get tired or drowsy when reading?*
  • (RBp2) Does your child get headaches when reading?*
  • (RBp3) Does your child get nauseous or sick when reading?*
  • (RBp4) Does your child open his/her eyes wide when reading?*
  • (RBp5) Does your child squint or frown when reading?*
  • (RBp6) Does your child blink frequently to try and make the print clear up?*
  • (RBp7) Does your child move closer to the page or back away when reading?*
  • (RBp9) Does your child have difficulty seeing words at a distance like the chalkboard in a classroom?*
  • (RBp10) Does your child look away often to take breaks when reading?*
  • (RBp11) Does your child stumble over words?*
  • (RBp12) Does your child complain that words on the page get blurry when reading?*

  • Your Child's Reading Behaviors - Eye Reactions

  • (RBer2) Do your child's eyes hurt, ache, or burn when trying to read?*
  • (RBer1) Do your child's eyes get red and watery when reading?*
  • (RBer3) Do your child's eyes feel dry, sandy, scratchy, or itchy when reading?*
  • (RBer4) Does your child need to rub his/her eyes frequently when reading?*
  • (RBer5) Does your child's eyes cross or one eye turn in or out when reading?*

  • Your Child's Listening Skills

  • (LS1) Does your child tend to daydream?*
  • (LS2) Is your child inattentive when spoken to?*
  • (LS3) Does your child need instructions repeated?*
  • (LS4) Does your child have a difficult time remembering instructions?*
  • (LS5) Does your child misinterpret what has been said?*
  • (LS6) Is your child distracted by surrounding noises?*
  • (LS7) Have other adults expressed concern about your child's listening skills?*

  • Your Child's Receptive Listening and Language

  • (RLa1) Does your child have difficulty staying focused at school or work?*
  • (RLa2) Does your child have a short attention span?*
  • (RLa3) Is your child easily distracted, especially by noise?*
  • (RLa4) Is your child over-sensitive to certain sounds?*
  • (RLa5) Does your child misinterpret questions and requests?*
  • (RLa6) Does your child have difficulty with sound discrimination?*
  • (RLa7) Does your child confuse similar sounding words?*
  • (RLa8) Does your child need repetition and clarification more than others?*
  • (RLa9) Is your child unable to follow more than one or two instructions at a time?*
  • (RLa10) Does your child have difficulty understanding discussions?*

  • Your Child's Receptive Listening and Language (Continued)

  • (RLb1) Does your child have poor short-term memory retrieval? (like remembering isntructions, telephone numbers, or zip codes)*
  • (RLb2) Does your child have poor long-term memory retrieval?*
  • (RLb3) Does your child tire easily with academic study?*
  • (RLb4) Does your child become sleepy when listening to lengthy teacher talks or instructions?*
  • (RLb5) Does your child have difficulty hearing low male voices?*
  • (RLb6) Does your child have difficulty hearing his/her father's voice?*
  • (RLb7) Does your child have difficulty hearing high female voices?*
  • (RLb8) Does your child have difficulty hearing his/her mother's voice??*
  • (RLb9) Does your child feel that most people speak too fast?*
  • (RLb10) Does your child feel that most people speak too slowly?*

  • Your Child's Expressive Listening and Language

  • (RLc1) Does your child speak with a flat or monotonous voice quality?*
  • (RLc2) Does your child have difficulty recalling exact word usage?*
  • (RLc3) Does your child mispronounce words when reading aloud?*
  • (RLc4) Does your child have difficulty summarizing a story?*
  • (RLc5) Does your child's speech lack fluency and rhythm?*
  • (RLc6) Does your child sing out of tune?*
  • (RLc7) Does your child have difficulty relating isolated facts?*
  • (RLc8) Does your child lisp?*
  • (RLc9) Does your child have difficulty pronouncing "R's"?*

  • Your Child's Level of Energy

  • (LE1) Does your child have difficulity waking up?*
  • (LE2) Does your child have a habit of procrastinating?*
  • (LE3) Is your child hyperactive?*
  • (LE4) Does your child have a tendency toward depression?*
  • (LE5) Does your child feel overburdened with everyday tasks?*

  • Your Child's Time and Organization Skills

  • (TO1) Does your child have trouble telling time on a clock with hands?*
  • (TO2) Does your child have trouble understanding time on a digital clock?*
  • (TO3) Is your child confused by the numbers on a digital clock; i.e. the number 5 and the number 2?*
  • (TO4) Does your child have trouble understanding the mechanics of time?*
  • (TO5) Does your child have trouble organizing and being organized?*
  • (TO6) Does your child have trouble understanding the difference between order and disorder?*

  • Your Child's Counting and Mathematics Skills

  • (CM1) Does your child have trouble counting change?*
  • (CM2) Does your child have trouble understanding math story problems?*
  • (CM3) Does your child have trouble counting backwards (from 100 to 1) as fluently as forwards (from 1 to 100)?*
  • (CM4) Does your child NOT understand the relationship of addition to subtraction?*
  • (CM5) Does your child understand the relationship of multiplication to division?*
  • (CM6) Does your child have trouble staying at grade level in mathematics?*
  • (CM7) Are your child's reasoning skills NOT appropriate for his/her age?*

  • Your Child's Abilities

  • Goals for Your Child

  • How I found you.

  • How did you find Meadowbrook Educational Services?*

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        MES Adult Assessment
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        Meadowbrook Educational Services, Inc. 11011 South Cedar Road, Spokane, WA 99224-9623

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