When filling out this form, please be as specific as possible. Include dates and other detailed information where applicable.

By typing my initials in this box, I consent to sharing my child's personal medical and psychological history with Cognitive Solutions Learning Center, Inc. and its employees. I understand that all information will remain confidential, and not be shared with anyone outside of Cognitive Solutions Learning Center, Inc. without prior written consent:

Your Name:

Child's Name:

Email:

Phone Number:

Relationship to child?

Child's date of birth:

Reason for requesting an assessment

Has your child had a previous psychological or educational evaluation? If yes, please describe in detail including type of evaluation and resulting diagnosis.

Please describe your child's current living situation:

Has your child been to the doctor in the past year? If so, how is the child’s current health? Is he/she being treated for anything?

Has you child had both hearing and vision screenings in the past year? Please describe:

Please describe any medical or physical problems your child has had:

Is your child currently taking medication, either prescription or over the counter? If yes, carefully list the specific medication and dose date first prescribed, who prescribed, and for what purpose:

Please list any medications your child has taken in the past, and the reason for the prescriptions:

Were there any problems or unusual circumstances during pregnancy or delivery? If yes, please describe:

Was the child adopted?

Were there any developmental problems including delay in learning to crawl, walk, or talk? If yes, please describe:

As a child, was he/she extremely physically active or always “on the go”?

Please provide a comprehensive school history, including name/type of schools attended and current school/grade level:

Please describe any of the following problems your child has experienced, including the time of onset for each: Reading difficulty, writing difficulty, mathematics difficulty, poor grades, homework problems, peer problems, and/or organizational problems:

Please describe your child’s greatest strengths and any special abilities or talents. What school subjects have he or she generally done best in?

What problems, if any, does your child have with fears, tension, anxiety, panic attacks, phobias, being uncomfortable in new situations, or shyness? How has this changed over time?

What problems, if any, does your child have with self-esteem? Are there particular things your child is most likely to feel bad about?

Does your child have any problems with sleep? If yes, please describe:

Please identify any blood relatives (i.e. "Dad's brother") who have or had learning or psychological difficulties of any kind:

Is there anything else it would be helpful to know about?