Student Name

Student Age

Student Gender

Date of Birth

Grade Entering Fall

Previous School

Recent Psycho-educational Evaluation? Recent Psycho-educational Evaluation? Yes No

Parent/Guardian Name

Parent/Guardian Phone

Parent/Guardian Email

Math - Which grade level did your child last complete?

Reading - Which reading level is your child on?

Writing - How does your child write?

Relationship With Other Children Relationship With Other Children Works well with others Generally, does not get along well Prefers working alone

Independent Skills Independent Skills Needs assistance/reminders to stay on task May need some assistance Usually takes initiative

Stability Stability Generally, under control Occasionally loses control Frequently loses control, outburst

Social Participation Social Participation Shy, withdrawn, won’t participate Will participate, needs encouragement Active participant

Adjusts to New Situations Adjusts to New Situations Excellent Good Fair Work needed

Relationship with Peers Relationship with Peers Excellent Good Fair Work needed

General Conduct General Conduct Excellent Good Fair

Shows Respect for Adults Shows Respect for Adults Excellent Good Fair Work needed

Shows Verbal Self-control Shows Verbal Self-control Excellent Good Fair Work needed

Shows Physical Self-control Shows Physical Self-control Excellent Good Fair Work needed

Follows Classroom Rules Follows Classroom Rules Excellent Good Fair Work needed

Shows Self-confidence Shows Self-confidence Excellent Good Fair Work needed