Child Form

Child Testing Intake Form

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

Transmission of this form is encrypted using SSL technology

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:

Please describe any of the following problems your child has experienced, including the time of onset for each: