Referral For Multidisciplinary Team Evaluation (7-12) Form Page 4
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4Referral for Multidisciplinary Team Evaluation (7-12)
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D.
School History
Please list in order the previous schools the child has attended
SCHOOL
LOCATION
GRADES
DATES
______________
______________
______________
______________
Has your child been retained? Yes
No
If yes, what grade:
Why? ____________
Has your child ever received special tutoring or therapy in school? Yes
No _____
If yes, describe _________________________________________________________________
Has your child received tutoring out of school? Yes _____ No _____
If yes, describe _________________________________________________________________
Has your child ever been formally evaluated? Yes
No
If yes, when and by
whom?_____________
Results (please provide copy) ___________________________________________________________
Describe your child’s interests ________________________________________________________________
_________________________________________________________________________________________
What are the positive characteristics that describe your child socially/emotionally?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
From the parent/guardian perspective, describe your child's current difficulties (academic or behavioral)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
When were these difficulties first noticed? _________________________________________________
What seems to help? __________________________________________________________________
What seems to make them worse? ________________________________________________________
Does your child exhibit any unusual or atypical behaviors for his/her age? Yes _____ No ____ If yes, describe:
__________________________________________________________________________________________
Has your child been seen by the school social worker? If so, describe the reason _________________________
__________________________________________________________________________________________
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 #: ____________________________________________
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