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PARENTAL INPUT FORM - ABBREVIATED
I. Demographics:
Student Name
*
First Name
Last Name
Date of Birth:
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Month
-
Day
Year
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Grade
*
School
*
Current Teacher(s)
*
Parent Completing Form
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
E-mail
*
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II. Observations
What are your child's strengths?
*
What are your present concerns, if any?
*
Please check all social/behavioral characteristics that best describe your child:
Flexibility
Daydreaming
Temper Tantrums
Artistic
Uncooperative
Creativity
Nail biting
Athletic
Self-confident
Sleep-walking
Frequent, sudden, changes in mood
Usually aggressive toward others
Enjoys reading
Difficulty using numbers
Outgoing
Cooperative
Unreasonable fears
Frequently tells lies
Frequently talks to self
Bedwetting
Mechanical
Musical
Difficulty with organization
Excessive inconsistency in behavior
Difficulty with change in routine
Difficulty telling time
Lacks Motivation
Consistently has short attention span
Nightmares
Fantasies
Avoids homework
Hard worker
Thumbsucking
Overactive
Underactive
Lacks self-control
Needs constant approval or assurance
Difficulty making or keeping friends
Avoids reading
Frequently late
Doesn't seem to understand questions or directions
Other
Describe the child's attitude and motivation towards school:
What are your goals for your child? (i.e., transition goals for high school or vocational)
III. Medical Updates
Are there any relevant medical updates you wish to share?
Please list medications child is currently taking, if any:
If you would like to share any medical documents, please upload here:
Upload a File
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IV. Additional Information
Have there been any recent traumatic events that the team and/or school should be mindful of?
Has the child received any private educational or psychological testing, therapy, or remediation that has not already been shared?
If you would like to share any reports regarding the above, please upload here:
Upload a File
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Is there any additional information you would like to include to assist with this evaluation?
At the conclusion of the evaluation, a meeting will likely need to be held. What is your general availability?
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