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:

Understanding words in conversation

Understanding words in reading and writing

Understanding and using antonyms/synonyms in conversation

Understanding and using antonyms/synonyms in reading and writing

Finding the appropriate words to use in a conversation

Speaking in grammatically correct sentences

Writing grammatically correct sentences

Using correct punctuation in writing

Identifying the names and sounds of written letters

Decoding real and nonsense words

Identifying rhyming words

Reading a variety of literary forms

Answering comprehension questions after reading an age appropriate story

Following written directions

Making inferences about details in a story

Reading words in sentences and paragraphs in a smooth, automatic way

Paraphrasing age appropriate text after reading

Spelling

Letter formation

Writing legibly

Following the main idea of conversational topics

Following routine and complex verbal directions

Initiating or maintain a conversation

Using or understanding figurative language in conversation (idioms, metaphors, humor)

Asking and answering questions during conversation

Beginning Tasks

Attending to Tasks

Completing Tasks