A Child Can Do All Things


Assessment Application Form

I. Child's Personal Information

Name:
Gender:
Date of Birth:
Child Resides with:
Address:
II. Parent/Guardian Information:

Mother's Name:
Address:
Home Phone:
Work Phone:
Email Address:
Father's Name:
Address:
Home Phone:
Work Phone:
Email Address:
Siblings:
Name:
Age:
Gender:
Name:
Age:
Gender:
Name:
Age:
Gender:
III. Medical & Health Record:

Weight at Birth:
Gestation Weeks:
Child's Diagnosis:
Any History of Epilepsy or Seizures:
Current Medications:
Surgeries:
Allergies:
Special Diet:
Hearing Tested and Results:
Vision Tested and Results:

Please give date of last medical exam(s):
Neurologist:
Orthopedics:
Previous treatments, therapies:
Is there any past Participation in Conductive Education programs:
Other Information/Comments you would like to share:
IV. Parent/Guardian Observations:

Describe your child’s daily routine: (Weekdays)
Describe your child’s daily routine: (Weekend)
What are your child’s favorite leisure activities?
How does your child express his/her wishes or needs? How does he/she communicate:
How does your child move around:
What is your child’s cognitive level:
Is it easy or difficult to motivate him/her:
At this time what kind of school and program is he/she enrolled in:
Please share any other information you would like:
V. Present Physical Condition:
Transitioning:
Sitting position:
Standing position:
Walking:
Fine motor skills:
Self-care skills:
What kind of special aides, furniture does your child use at home:
VI. General Questions:

What goals do you have for your child?
Do you expect to reach these goals with Conductive Education?
How did you hear about A Child Can Do All Things?
This application has been completed by:
Name:
Relationship:
Date:
Please fill out online or mail your completed Assessment Application Form and any additional medical or educational reports if available.

A Child Can Do All Things
12870 Hillcrest Road H-101
Dallas, Texas 75230

Once A Child Can Do All Things has received your child's assessment form, we will contact you regarding an evaluation date or an evaluation video for your child.

 


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