Name:
Age:
Birthdate:
Test Date:
School:
Grade/Class:
Examiner:

Reason for Referral:
 

Background Information:
 

Assessment Questions:

After some discussion with Client's name's family, the following questions emerged:

1.  What is Client's name's overall level of ability?

2.  At what level is Client's name functioning in reading, written language and mathematics?

3.  At what level is Client's name functioning academically?

4.  What is the nature of Client's name's oral language problems?

5.  What factors are interfering with Client's name's progress in school?

6. Does Client's name have Attention Deficit Hyperactivity Disorder (ADHD)?

7.  What is the nature of Client's name's learning disability?

8.  What is the nature of Client's name's learning problems?

9.  What learning strategies does Client's name employ?

10.What coping strategies does Client's name employ?

11.What compensatory strategies does Client's name employ?

12. How is Client's name functioning socially and emotionally?

13. To what extent is Client's name's learning problems affecting him/her socially and emotionally?

14. To what extent are Client's name's emotional and social problems affecting him/her academically?

15. To what extent does Client's name's profile suggest that he/she is intellectually gifted?

16. How does Client's name learn best?

17. What is the nature of Client's name's life skills?

18. What factors should Client's name consider when making career decisions?

19. Are Client's name's vocational goals appropriate?

20. What is an appropriate educational placement for Client's name?

21. What is an appropriate educational program for Client's name?

22. What is an appropriate educational placement and program for Client's name?

23. What types of enrichment activities are appropriate for Client's name?

24. How can Client's name's parent(s) help Client's name at home?

25. What additional assessment(s)/treatment(s) are required for Client's name?

Each of these questions is discussed in turn.

Assessment:
 

Conclusion:
 

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Name
Position