application for assessment - learning resource...
TRANSCRIPT
Application For AssessmentAges: 0-6 years old
Child’s Name:____________________________________________________
(First) (Middle) (Family Name)
Age: _____Male/Female:________ Nationality: ________ Date of Birth:________(d/m/yr)
Place of Birth: __________________
Home Address: (please indicate district, i.e. Maadi, Zamalek, Giza, Sidi Bishr, …etc)
________________________________________________________________________________________
____________________________________________________________________
Father’s Name: ______________________________________________________________
Tel Hm #: __________________Wk #________________Mob #________________________
Email: __________________________
Address (if different than child’s) _________________________________________________
Mother’s Name: _____________________________________________________________
Tel Hm #: __________________Wk #________________Mob #______________________
Email: __________________________
Address (if different than child’s) __________________________________________
Primary language of family: ____________Language preference for intake: _____________
If non Egyptian, how long do you expect to be a resident in Egypt? ____________________
Please list specific problems your child is experiencing and / or your concerns:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Please list what you would like us to provide:
_____________________________________________________________________________________
How did you learn about the center? __________________________________________________________________________
Building 9'' Road 278, New Maadi, Cairo Tel: 25163965-25163967-27543814Mob:0122-233-2809-0127-4040-397Website : www.lrcegypt.org
email : [email protected]
Office use only: Date received: Paid: (yes/no) Date Entered:
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Family History: Natural Father’s present age:___________School level completed:_____________________
Present Occupation:___________________________________General Health:_____________
Natural Mother’s present age:__________School level completed:_____________________
Present Occupation:___________________________________General Health:_____________
List all brothers and sisters of this child: (N=natural, H=half, A=adopted)
Names N H A Age Sex(M/F)
School / Grade
Please check any of the following that are true of this child:
Was adopted □ Lives with guardian □
Parents are: Separated □ Divorced □ Related □
Are either parents’ deceased □ if yes, please specify (--------------)
With whom does the child live? (please list all members of household, name, and
relationship to the child)
_____________________________________________________________________________
_____________________________________________________________________________
Legal guardian (if different from above, name and relationship to the child)
_____________________________________________________________________________
Has this child endured any extremely stressful experience?
If so, please describe: _______________________________________________________
_________________________________________________________________________
Please note hours each week spent with your child and activities shared:
Hours Weekly Activities
Mother: ____________ ______________________________________________
Father: ____________ ______________________________________________
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How many hours weekly does your child spend:
With household staff: __________________Watching T.V. or video: _________________
Playing computer games: _______________Doing homework: _____________________
Reading together: _____________________Playing Sports: _______________________
Family History Child’s
Mother
Child’s
Father
Child’s
Brother(s)
Child’s
Sister(s)
Others
(specify)
Attention problems/ excessive activity levels
Trouble learning to read
Trouble with arithmetic
Trouble with writing
Kept back in school
Left handed or ambidextrous (please specify)
Speech/ Language problems
Behavior problems in childhood
In trouble as a teenager
Depression
Other mental illness
Drinking problem or drug abuse
Serious health conditions
Allergy
Blood Disease
Cancer
Cerebral Palsy
Heart Disease
Mental Retardation
Muscular Dystrophy
Seizures/ Epilepsy
An Honor Student
Please note any particular strengths and/or interests of your family members:
__________________________________________________________________________3
Medical History:The following checklists help us to decide whether there are any early medical factors that might be important
Pregnancy History
True
Not
Tr
ue
Can
not
Say
Had previous miscarriagesHad previous premature baby (ies)There was unusual emotional stressThere was unusual physical stressInvitro fertilization was requiredHad bleeding during first three monthsHad bleeding during second three monthsHad bleeding during last three monthsGained 30 or more Ibs. (14 Kgs.) (specify -------)Had toxemiaHad to take medicationsVomited oftenGot hurt or injuredGained less than 15 Ibs. (7 Kgs.) (specify -------)Suffered from DiabetesRhesus incompatibilityHad an infectionSmoked one pack (or more) of cigarettes a dayPregnancy was full term? ---------Wks?Labor lasted longer than 12 hoursLabor lasted less than two hoursThere were problems with the baby: during labor, delivery, before leaving the hospital? (circle which)Your age was less than 20 or more than 35 when this child was born?Had a difficult deliveryWas put to sleep for deliveryMethod of delivery? (circle appropriate answer)Normal breech caesarian forceps used induced vacuum extraction
Specify any medications during pregnancy: Other pregnancy problems/ illnesses:
1. …………………………………… …… 1. ……………………………………
2. ………………………………………… 2. …………………………………….
3. ………………………………………… 3. …………………………………….
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Newborn Infant Conditions
True
Not
Tr
ue
Can
not
Say
Born with cord around neckInjured during birthHad trouble breathingTreated with photo-therapy for jaundiceTurned blue (cyanosis)Was a twin or tripletHad an infectionWas given medications*Had seizures (fits, convulsions)Had diarrhea frequentlyNeeded oxygenGagged oftenVomited oftenBaby had extended stay in hospital after birth? For how long? ------------Born with heart defectBorn with other defect(s)Child breast-fed? For how long? -----------Had trouble sucking / or swallowingHad an X-ray of the headIf premature, was your child put in an incubator?This was an easy baby, i.e. little crying or fussing, followed daily schedule fairly well?Baby’s birth weight --------------Ibs., Kgs.
Please list any other problems that occurred during delivery, or first week of life
1. ________________________________________________________________________
2. ________________________________________________________________________
3. ________________________________________________________________________
4. ________________________________________________________________________
* Specify medications and for what condition
1. ________________________________________________________________________
2. ________________________________________________________________________
3. ________________________________________________________________________
4. ________________________________________________________________________
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Following is a checklist of early accomplishments of children. Please respond by putting AGE next to each item under the column giving the approximate age at which this “milestone” first occurred. If there are items the child still cannot, please check “Not Yet Able”.
Early Development
0-3
mon
ths
4-6
mon
ths
7-12
mon
ths
13-1
8 m
onth
s
19-2
4 m
onth
s
2-3
year
s
3-4
year
s
4-5
year
s
5-6
year
s
Not
Yet
Abl
e
Sat up without helpCrawledWalked alone (10-15 steps)Walked up stairsRode a tricycleCaught a big ballSpoke first words (Mama, Dada, etc.)Put words together (Daddy bye-bye, Mama home, etc.)Spoke 2-3 word sentencesSpoke clearly so strangers understoodUsed fingers to feed selfUsed a spoonFully bowel trained (stools)Fully bladder trained (urine)Able to separate easily from mother (for school, play, etc.)
Has your child had any problems with coordination? Yes/No
If yes, explain and give age: ______________________________________________________
_____________________________________________________________________________
Did your child have any problems learning how to dress him or herself? Yes/No
If yes please explain: ___________________________________________________________
_____________________________________________________________________________
At what age was your child able to button his/her clothes? __________________
dress self completely? _________________ tie his/her shoes? _____________________
At what age did you discover your child was right handed or left handed? _____________
Does your child speak more than one language? Please Specify? _________________________
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How does your child primarily communicate __________? (gesture, single word, 2-3 word phrase, sentences)
What does your child like to play with? _____________________________________________
Please list favorite play activities? _________________________________________________
Who does your child like to play with? _____________________________________________
Tick phrases that describe your child’s play:
□ alongside others only □ adults only □ only with siblings
□ best with only one child □ shares with others □ interacts with other children
□ follows a theme in play □ is aggressive □ moves rapidly from one toy to another
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Please put an X in the column under the age at which the problem(s) occurred over a long period, or over and over again, Place checks
in the columns for each age during which the problems existed. If the child has never had the problem, put an X in the “never” column
Health Conditions
Nev
er
0-3
mon
ths
4-6
mon
ths
7-12
mon
ths
13-1
8 m
onth
s
19-2
4 m
onth
s
2-3
year
s
3-4
year
s
4-5
year
s
Sinc
e 5
year
s
Ear infection(s)Rashes or skin problemsMeningitisSeizures (convulsions) or fainting spellsHigh fevers (over 103F or 39C)PneumoniaAsthmaSlow weight gainTrouble with ears or hearingTrouble with eyes or visionBowel problemsHospitalization(s)Surgery (operation)Head injury/ other injuriesFood allergiesOther allergiesAnemia (low blood count)Lead poisoningOther poisoning or overdoseHeart problemsKidney or urinary problemsGot sick after a shot (immunization)- Drools- Difficulty with swallowing- Difficulty chewing crisp foods or meat- Tongue protrude- Breath consistently through mouth
with/without snoring- Liquid escape through mouth or nose
when drinkingOther important illnesses: accident, injury or operations (specify)a. -----------------------------------b. -----------------------------------c. -----------------------------------
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Medications used over a long period (specify name reason for use): --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Please give reasons for hospitalizations or surgery:
_____________________________________________________________________________
_____________________________________________________________________________
Please list any medical diagnosis, date, and name of physician?
___________________________ ________________ _________________________
___________________________ ________________ _________________________
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The following section will help us in focusing on any specific difficulties your child may be experiencing. Please put an X in the column under the age at which the problem(s) occurred over a long period, or over and over again, Place checks in the columns for each age during which the problems existed. If the child has never had the problem, put an X in the “never” column
Functional Conditions in Early Life
Nev
er
0-3
mon
ths
4-6
mon
ths
7-12
mon
ths
13-1
8 m
onth
s
19-2
4 m
onth
s
2-3
year
s
3-4
year
s
4-5
year
s
Sinc
e 5
year
s
Difficulty in keeping to a scheduleProblems going along with changes in daily routineExtreme restlessnessTendency to become overexcitedTrouble getting satisfiedDesire to be held too oftenDifficulty getting consoledOver-reaction to sights or noisesExtreme reaction to tastes or touchingTemper tantrums/ anger outburstsTrying to hurt others when angryIrritabilityCrying often and easilyRaising voice a lotActing too sad or too excitedTrouble falling asleepTrouble staying asleepExcessive need for sleep nearly everydayVery heavy sleepNoisy breathing/snoring in sleepFrequent naps during dayUnpredictable length of sleepSleep walking / talkingFeeding difficultyExtremes of hungerEating non-foodsUnusual food preferences? Explain: -----------------------------------------------------------------------Poor appetiteColic
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Functional Conditions in Early Life (cont’d)
Nev
er
0-3
mon
ths
4-6
mon
ths
7-12
mon
ths
13-1
8 m
onth
s
19-2
4 m
onth
s
2-3
year
s
3-4
year
s
4-5
year
s
Sinc
e 5
year
s
ConstipationStomach achesHead bangingRocking in bedExcessive thumb suckingSelf-destructive behaviorTrouble making eye contactFailure to be affectionateMaking odd sounds, grunts or noisesJerking arms or head oftenStiffness or rigidityLooseness or floppinessShyness with strangersBashfulness with other childrenUnrealistic and often worried about possible harm to care giversPersistently refuses to be aloneNeeds excessive reassuranceFrequently unable to relaxComplains often about varied medical symptoms (headache, fatigue, or stomachache)Persistently refuses to sleep aloneHas repeated nightmares Has extreme fearsHas unusual fears
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School History:
School Attended
Pre-school/Nursery/ Primary
Dates Language of
Instruction
Please X:
Problems with
From To Learning Behavior
* Attach or bring copies of school progress reports to initial interview meeting
When Comment
Has your child ever received special services at school?Has your child ever repeated a grade in school?Has your child ever been suspended or expelled?Does your child persistently refuse to go to school?
Has your child ever had an assessment of:
Date Result Follow-up therapy
Vision
Hearing
Speech/Language
Neurological Function
Other:
* Attach copies of previous assessment reports
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AUTHORIZATION FOR LRC TO RELEASE INFORMATION
Name :________________________ DOB:_________________________
Release Information to :_________________________________________
I hereby authorize the Learning Resource Center to release and/or exchange information as indicated below regarding my child, whose name appears above, to school, agency and or person also listed above.
Release of Written Evaluation Reports
Psycho-Educational or Cognitive Testing Academic Testing Speech/ Language Occupational or Physical Therapy Counseling Reports Release of Medical Records
Other
Please DO NOT release information.
This release will be in effect for 1 year.
__________________________ __________________________ Date Parent / Legal Guardian
Building 9'' Road 278, New Maadi, Cairo Tel: 25163965-25163967-27543814Mob:0122-233-2809-0127-4040-397Website : www.lrcegypt.org
email : [email protected]
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AUTHORIZATION FOR RELEASE of INFORMATION TO LRC
Child’s Name: _______________________ School / Professional____________________
D.O.B:________________________
Grade : ________________________ School / Professional’s Phone Number: ________________________________
I hereby authorize the above named school or professional to release and/or exchange information as indicated below regarding my child , to the Learning Resource Center and _______________________ ( LRC staff-member)
Teacher/School Personnel Interview Classroom ObservationReview of School Records
Release of Written Evaluation Reports
Psycho-Educational or Cognitive Testing Academic Testing Speech/ Language Occupational or Physical Therapy Counseling Reports Release of Medical Records
Other
I DONOT authorize the LRC to contact ________________ for information regarding my child.
This release will be in effect for 1 year.
__________________________ __________________________ Date Parent / Legal Guardian
Building 9'' Road 278, New Maadi, Cairo Tel: 25163965-25163967-27543814Mob:0122-233-2809-0127-4040-397Website : www.lrcegypt.org
email : [email protected]
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