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January 06, 2009

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Assessment Application Form





I. Child's Personal Information

Name:	Gender:	Date of Birth:
Child Resides with:	Address: (Street/City/State/Zip)


II. Parent/Guardian Information:

Mother's Name:	Address: (if different than child)
Home Phone:	Work Phone:	Email Address:
Father's Name:	Address: (if different than child)
Home Phone:	Work Phone:	Email Address:
Siblings:
Name:	Age:	Gender:
Name:	Age:	Gender:
Name:	Age:	Gender:



III. Medical & Health Record:

Weight at Birth:	Gestation Weeks:
Child's Diagnosis: (what is it; when was it given)
Any History of Epilepsy or Seizures: (what kind; how often; how long; main symptoms)
Current Medications:
Surgeries: (what kind; when)
Allergies: (food, medications etc.)
Special Diet: (G-tube, etc.)
Hearing Tested and Results: (when/what results)
Vision Tested and Results: (when/what results)

Please give date of last medical exam(s):
Neurologist:	Orthopedics:
Previous treatments, therapies: (PT, OT, Speech, other services; how often)
Is there any past Participation in Conductive Education programs: (when, where)
Other Information/Comments you would like to share:

IV. Parent/Guardian Observations:

Describe your child’s daily routine: (Weekdays)
Describe your child’s daily routine: (Weekend)
What are your child’s favorite leisure activities? (Home, Favorite toys/games, Outside)
How does your child express his/her wishes or needs? How does he/she communicate: 1. Does you child speak words and sentences? 2. Does he or she follow instructions? 3. Does he/she uses a communication device?
How does your child move around: In the house: Outside:
What is your child’s cognitive level: (Age appropriate, somewhat delayed, very delayed)
Is it easy or difficult to motivate him/her: What motivates him/her (peers, toys, songs...)
At this time what kind of school and program is he/she enrolled in: How many times a week does he/she attend and for how many hours at a time? What kind of activities does he/she do while there?
Please share any other information you would like:




V. Present Physical Condition:
Transitioning: Is he/she able to? Roll over: Creep (commando crawl): Crawl: Stand up by furniture/ walker:
Sitting position: Is he/she able to? Sit on the floor: Sit in chair/ on a bench (supported, unsupported):
Standing position: Is he/she able to? Stand by furniture: Walker: Canes: Independently:
Walking: Is he/she able to? Take steps when held: In gait-trainer: Walker: Canes: Independently:
Fine motor skills: Is he/she able to? Grasp and hold different things (blocks, pencil, paper, etc.): Release objects intentionally: Use pincer grasp: Point to pictures:
Self-care skills: Is there any problem with chewing or swallowing? Does he/she use any special utensils? Can he/she feed self with finger food? Describe what stage he/she is in regarding toilet training?
What kind of special aides, furniture does your child use at home:



VI. General Questions:

What goals do you have for your child?
Do you expect to reach these goals with Conductive Education?
How did you hear about the Conductive Education center of Orlando?
This application has been completed by:
Name:	Relationship:	Date:
Please, fill out online or mail your completed Assessment Application Form and any additional medical or educational reports if available.
Mail application materials to: Conductive Education Center of Orlando 4800 Howell Branch Road Winter Park, FL 32792 Phone: 407-671-4687 Fax: 407-647-3833 Further contact will be made with you regarding assessments dates. If you will not be able to travel to Florida, submitting a video following the Video Assessment Guidelines will suffice. Go to our website to see the video guidelines. Thank you. www.seewhatachildcando.org



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