Referral For Initial Multidisciplinary Team Evaluation (50 Day Timeline) Form Page 5
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5Does your child have any difficulties with:
Large motor skills (i.e. walking, riding a bike, etc.)?
Small motor skills (i.e. using hands, cutting/writing, etc.)?
o No o Yes - describe: _ _______________________
o No o Yes - describe: _ ___________________________
____________________________________________
________________________________________________
Some students display unusual behaviors that interfere with daily activities. Please rate your child on the following
behaviors;
Grinds teeth
o Does not Occur o Occasional o Frequently
Poor eye contact
o Does not Occur o Occasional o Frequently
Very sensitive to pain
o Does not Occur o Occasional o Frequently
Intensely aware of smells
o Does not Occur o Occasional o Frequently
Highly sensitive to certain sounds
o Does not Occur o Occasional o Frequently
Chews/Mouths clothes/inedible objects
o Does not Occur o Occasional o Frequently
Extremely limited food preferences
o Does not Occur o Occasional o Frequently
Hurts self (biting, head banging, cutting etc.)
o Does not Occur o Occasional o Frequently
Please provide additional information regarding above concerns: __________________________________________
_______________________________________________________________________________________________
Does your child exhibit any other unusual or atypical behaviors for his/her age? o No o Yes - please describe: ____
_______________________________________________________________________________________________
SCHOOL HISTORY
Did your child attend preschool o No o Yes - indicate (place and year) ____________________________________
Please list in order the previous schools the child has attended
School
Location
Grade(s)
Dates
__________________________
______________________________
____________
__________________
__________________________
______________________________
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__________________
__________________________
______________________________
____________
__________________
Has your child been retained? o No o Yes in _______ grade.
Has your child ever been formally evaluated? o No o Yes by SBCSC (in ___ grade) o Yes outside of this school
corporation (e.g. Riley Children’s Hospital, Stepwise, Oaklawn, etc; indicate who and when testing occurred)
_________________________________________________________________ If yes, please provide copy of results.
Has your child ever had a 504 Plan? o No o Yes - When and Why? _ _______________________________________
Has your child been seen by the school social worker? o No o Yes - When and Why? _ ________________________
_______________________________________________________________________________________________
Describe anything else that the assessment team should know about your child.
_______________________________________________________________________________________________
What are the best days/times for you to meet:
Days ___________ Times __________ Phone # __________ Email _____________________
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