Evaluation Report Form

Four weeks after you first begin program activities, please submit this form with four program tracking sheets. This form must also be submitted before each re-evaluation.

You can now save this form. If you go all the way to the bottom of the form there is the option to save. You will be emailed a link that will take you to your incomplete form.

Today's Date:*

MonthDayYear

Best Contact Phone Number:*

Area CodePhone Number

Evaluator's Name:*

Jan BedellOther

Client's Name:*

First NameLast Name

Best Contact E-mail:*

Client's Age*

Client's Grade Level (if a student)

Client's Height*

Client's Weight*

Parent or Guardian's Name (if applicable):*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Has your address changed since your last evaluation?

Please list any medications or dietary supplements which the client is receiving. If there are none, please type n/a in the blank below:*

Please indicate any dietary limitations or if the client has specific dietary requirements. If there are none, type n/a in the blank below:*

Please indicate if there have been specific health problems that have occurred since the client's last evaluation. This would include seizures, infections, operations, broken bones, sleep issues, etc...*

Please indicate schools / classes being attended, extra curricular activities, therapies or the client's employment status.*

Please indicate the percentage of the total plan completed since the last evaluation:*

0% - 25%26% - 50%51% - 75%76% - 100%

List any activities that have not been accomplished and why:*

Please make specific comments in each of the areas below, relative to the INP. Please include successes, changes, concerns, difficulties and/or other observations.

Tactility- Please include comments about hypo / hyper sensitivity to touch, temperature or bath / shower and sensitivity to odors. Also indicate any specific food dislikes and whether it is due to taste or texture as well as if the client is irritated by tags and seams or if there are any bed wetting issues.*

Auditory Function- Please include any comments about the client's ability to follow directions, memory, attention span, hyper-sensitivity to sound, etc...*

Please indicate the client's auditory processing levels in the following areas (where applicable) at the time of previous testing:

Auditory Digit Span level at previous testing:

Auditory Numbers & Letters Mixed level at previous testing:

Auditory Conceptual Words (ACWS) level at previous testing:

Auditory Object Sequences (AOS) level at previous testing:

Please indicate the client's auditory processing levels in the following areas (where applicable) at the current level of testing:

Current Auditory Digit Span level:*

Current Auditory Numbers & Letters Mixed level:

Current Auditory Conceptual Words (ACWS) level:

Current Auditory Object Sequences (AOS) level:

If the client is receiving Samonas Sound Therapy please indicate the current CD, the number of times per day the client is listening and the number of minutes per day:

Visual Function- Make comments here on the client's visual function. This includes any letter and/or number reversals, eye convergence and tracking issues, eye contact, etc..*

Please indicate the client's visual processing levels in the following areas (where applicable) at the time of previous testing:

Visual Digit Span (VDS) level at previous testing:

Visual Flash Digit (VFD) level at previous testing:

Visual Object Sequence level at previous testing:

Please indicate the client's visual processing levels in the following areas (where applicable) at the current level of testing:

Current Visual Digit Span (VDS) level:

Current Visual Flash Digit (VFD) level:

Current Visual Object Sequence level:

Manual / Fine Motor Function- Please include any comments regarding the client's manual or fine motor function. This includes opening jars, print or cursive writing, pencil grasp, typing, etc...*

Language- Describe the client's language abilities. Comments should include concerns or progress in relation to articulation (pronouncing word/sounds correctly), fluency, conversational skills, misinterpretation of spoken words, stuttering, mouth breathing, etc...*

Mobility/Gross Motor Function- Describe the client's abilities in regards to mobility/gross motor function. This area includes crawling, walking, coordination, balance, endurance, best time achieved for a one-mile run or three-mile walk, etc.*

Academic Function

Please complete the blanks for the applicable areas below. If not applicable, please leave the field blank.

Early Learning Foundations (Level and page number):

Visual Circle Math (Last step introduced) Include challenges or questions about how to proceed:

Math (book/curriculum being used along with level and page number):

Counting CD (track number):

Skip Count CD (track number or numbers mastered):

Rapid Recall - Which operation and what track number:

Keys to _____ (book) and page number:

Handwriting (book and page number):

"What Your ___ Grader Needs to Know (book and page number):

Word Flash computer game (level and track):

New Practice Reader (level and page number):

Reading About Science (level and page number):

Reading for Concepts (level and page number):

Pathways Reader (book and page):

Basic Reading Instruction (BRI) (level and book number):

Advance Reading Instruction (ARI) (level, book number and page number):

Detailed Reading Comprehension (101,201,301 - include sentence number); be specific about the progress when reading the sentence one time and filling in the answer sheet without looking back:

Other reader and page number:

Sequential Spelling (level and page number):

SAT/Vocabulary Cartoons (book and page number):

Phonics program:

Geography / History:

List any other curriculum used and current level or page number below:

Behavior and emotionality- Please comment on any changes in cooperation, over sensitivity, hurt feelings, overreactions, tantrums, rigidity, flexibility, moods, depression, attitude, obedience, cooperation, frustration level, aggressive / destructive behavior, good/bad days, avoidance, tics, phobias, etc...*

Please note the current discipline/behavior management system being used:*

Indicate the level of concern for the following behaviors:*

	No Concern	Mild Concern	Concerned	Moderate Concern	Very Concerned
short attention span
hyperactive
hypoactive
rigid or inflexible
impulsive
explosive temper
anger (not explosive)
aggressive
destructive
low frustration level
disorganized
poor judge of time
emotional
temper tantrums
competitive
cooperative
follow through
desire to withdraw
phobias
suicidal

Please indicate the level of concern for the following behaviors:*

	No concern	Mild concern	Concerned	Moderate Concern	Very Concerned
difficulty following directions
difficulty with parents
difficulty with siblings
difficulty with peers
difficulty with teachers
few or no friends
socially immature
perseveration (endless repetition)
avoidance behavior
cyclical behavior
cyclical achievement / academics
tics
overly sensitive to pain
overly sensitive to sound
overly sensitive to odor
overly sensitive to taste
high pain tolerance
sucks thumb
bites nails
overly sensitive to texture

Social- Make comments here about the client's abilities in regards to interacting with others. This would include interactions with friends, siblings, appropriate play, etc...*

The portion below is one of the most important parts of communicating how things are going with program activities! Your input on EVERY PROGRAM ACTIVITY is vital for the evaluation team of the evaluator, program writer, and support personnel. We can support you better and create a more effective program with thorough information. Please give as many details as possible.

In the boxes below, list each one of your current activities from the INP by name. Add specific comments regarding successes, changes, concerns, difficulties, etc. should accompany each program activity whether it was completed consistently or not.

Activity 1*

Activity 2*

Activity 3*

Activity 4*

Activity 5*

Activity 6*

Activity 7

Activity 8

Activity 9

Activity 10

Activity 11

Activity 12

Activity 13

Activity 14

Activity 15

Activity 16

Activity 17

Activity 18

Activity 19

Activity 20

Activity 21

Activity 22

Activity 23

Activity 24

Activity 25

Activity 26

Activity 27

Activity 28

Activity 29

Activity 30

Name at least one positive change you have seen this quarter. Please be specific.*

Other families need your encouragement. Every victory, large or small is valuable! If LGS has your permission to publish your partially identifying information, fill out the fields below.

Parent /Guardian Initials:

City, State