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I. Child's Personal Information
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Name:
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Gender:
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Date of Birth:
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Child Resides with:
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Address:
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II. Parent/Guardian Information:
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Mother's Name:
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Address:
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Home Phone:
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Work Phone:
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Email Address:
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Father's Name:
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Address:
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Home Phone:
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Work Phone:
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Email Address:
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Siblings:
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Name:
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Age:
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Gender:
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Name:
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Age:
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Gender:
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Name:
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Age:
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Gender:
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III. Medical & Health Record:
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Weight at Birth:
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Gestation Weeks:
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Child's Diagnosis:
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Any History of Epilepsy or Seizures:
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Current Medications:
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Surgeries:
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Allergies:
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Special Diet:
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Hearing Tested and Results:
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Vision Tested and Results:
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Please give date of last medical exam(s):
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Neurologist:
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Orthopedics:
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Previous treatments, therapies:
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Is there any past Participation in Conductive Education programs:
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Other Information/Comments you would like to share:
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IV. Parent/Guardian Observations:
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Describe your child’s daily routine: (Weekdays)
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Describe your child’s daily routine: (Weekend)
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What are your child’s favorite leisure activities?
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How does your child express his/her wishes or needs? How does he/she communicate:
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How does your child move around:
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What is your child’s cognitive level:
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Is it easy or difficult to motivate him/her:
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At this time what kind of school and program is he/she enrolled in:
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Please share any other information you would like:
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V. Present Physical Condition:
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Transitioning:
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Sitting position:
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Standing position:
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Walking:
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Fine motor skills:
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Self-care skills:
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What kind of special aides, furniture does your child use at home:
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VI. General Questions:
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What goals do you have for your child?
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Do you expect to reach these goals with Conductive Education?
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How did you hear about A Child Can Do All Things?
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This application has been completed by:
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Name:
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Relationship:
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Date:
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| 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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