Name of child *

First Name

Last Name

What services (if any) has your child received before?

Speech Therapy

Occupational Therapy

Reading Support

Tutoring

Other

Does your child have difficulty with any of the following:

Spelling

Letter Formation

Writing Legibly

Stamina for writing

Taking his/her time when writing

Pencil grip

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)

Beginning Tasks

Attending to Tasks

Completing Tasks

Have difficulty managing clothing, fasteners, or tools (toothbrush, fork during meals)

Coloring

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

puzzles

keeping place on page while reading

organization skills

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

self-stimulatory behavior

planning new movement patterns

craving more or less movement than other children his/her age