Child Learning Disability Assessment
Please complete this form to help us assess potential learning disabilities in your child. All information will be kept confidential.
Child's Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent/Guardian Name
*
First Name
Last Name
Relationship to Child
*
Please Select
Mother
Father
Guardian
Other
Contact Email
*
example@example.com
Has your child been previously diagnosed with any learning or developmental disability?
*
Yes
No
Areas of Concern (Select all that apply)
*
Reading
Writing
Mathematics
Attention/Focus
Memory
Social Skills
Other
Please rate your child's skills in the following areas:
*
Rows
Below Average
Average
Above Average
Reading comprehension
1
2
3
Spelling and writing
4
5
6
Basic math skills
7
8
9
Attention span
10
11
12
Following instructions
13
14
15
Social interaction
16
17
18
How often does your child experience the following difficulties?
*
Rows
Never
Sometimes
Often
Always
Difficulty paying attention
19
20
21
22
Trouble remembering instructions
23
24
25
26
Avoids reading or writing tasks
27
28
29
30
Struggles with organization
31
32
33
34
Difficulty making friends
35
36
37
38
Overall, how would you rate your child's academic performance?
*
1
2
3
4
5
Please describe any additional concerns or relevant background information.
Submit Assessment
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