Name of person filling out the form (relationship to child)
Name of child
Name of child
Best Email Address to use for contacting you / scheduling
DOB of child
Grade in school
Does your child wear glasses?
If Yes, please indicate visual impairment
What are your child's strengths?
What are your child's weaknesses?
What services (if any) has your child received before?
Does your child have difficulty with any of the following:
Stamina for writing
Taking his/her time when writing
Pressure with writing utensil on paper (too light or too hard)
Spacing between words and sentences
Sizing of upper- and lower-case letters
Body alignment when writing (face, hands, trunk, arms, legs)
Staying on the lines when writing
Writing straight lines
Breaking pencil often
Pace when writing (too slow or too fast in comparison with peers)
Attending to Tasks
Have difficulty managing clothing, fasteners, or tools (toothbrush, fork during meals)
Opening snack / drink containers
managing clothing - getting dressed or undressed
managing backpack and/or lunchbox
reversing letters after first grade
naming / matching colors, letters, numbers, shapes
keeping place on page while reading
locating desired objects in room, on desk, in bag
keeping track of papers and assignments
keeping areas neat in the house
keeping backpack organized
putting thoughts in order
with loud noises/sounds
unusual responses to touch
planning new movement patterns
craving more or less movement than other children his/her age
What else do you want your clinician to know?