Parent Input Form for Schools/Evals

NOTE: ONLY COMPLETE THIS IF YOU HAVE SIGNED/APPROVED A PRIOR WRITTEN NOTICE FOR INITIAL EVALUATION (OR REEVALUATION) AND REQUEST FOR CONSENT FORM. IF YOU ARE NOT SURE, PLEASE CONTACT THE SCHOOL TO CONFIRM.

Student Name:

Date of Birth:

School:

Grade:

Current Teacher:

Today's Date:

Parent Completing Form:

Best Phone Number to be reached at:

Email:

If your child attended preschool, please list the years and places he/she attended:

Does your child enjoy being read to? If yes, what are the books he/she enjoys?

What are your child's strengths?

What are your child's needs or weaknesses?

What suggestions do you have for your child's educational program?

List any concerns you have regarding your child's current program and placement:

Please list any additional information regarding your child's academic, emotional, or medical needs that you feel will assist the team with your child's evaluation including speech and language (reading, comprehending spoken language, articulation, fluency, voice).

Describe any school related problems other family members have experienced including speech and language (reading, comprehending spoken language, articulation, fluency, voice).

Has your child had any evaluations that the school may be aware of? Check all that may apply:

Please upload any electronically saved evaluations or other relevant documentation.

Upload a File

Please provide any additional information regarding any above mentioned evaluations (dates, evaluators, etc).

Would you like for us to communicate with past or current evaluators, healthcare professionals, or other relevant providers? If yes, a signed Release form will be needed.

What is your child's primary language:

What is the primary language spoken at home?

Does your child understand or speak a language other than English? Please explain:

With whom does the student reside with? (Parents, siblings, grandparents, extended family, guardian, etc)

Describe any serious health problems mother experienced during this or other pregnancies:

If problems occurred, please list the month(s)

Birth Weight:

Apgar scores:

Did any of the following occur during the birth process?

If Other was checked, please provide additional details below:

Describe any difficulties your child had in learning to eat sleep, sit, walk, and talk:

Describe briefly any traumatic events that your child has experienced: (For example: death of a close relative, divorce, family crisis, etc.)

Please indicate any delays in the following developmental milestones:

If any of the above items were checked, please provide additional details below:

Please provide the approximate age below of any illness or problems your child has had:

Please describe any of the problems indicated above:

Has your child ever been hospitalized?

Details of hospitalization?

Has your child ever had any surgeries?

Details of surgeries?

Is your child currently under medical treatment or taking medications?

Details of medications?

Is your child's hearing normal?

Is your child currently in therapy?

Has your child been in therapy?

If yes, please list type of therapy, frequency of sessions , and the name of the provider:

If yes, please list type of therapy, number of sessions per month, and the names of the provider: (Please provide the school district with any therapy evaluation(s) and/or reports.)

Please rate your child's general health:

Please check all social/behavioral characteristics that best describe your child:

Please comment on any behaviors that particularly concern you:

At the conclusion of the evaluation, a meeting will need to be scheduled to discuss the findings and next steps. What is your availability generally like?

SDCT Parent Input & Developmental History Form