Child & Adolescent Assessment Information Packet

III. Previous Evaluations

For each category, please list any previous evaluations, examiners, dates, and results.
Health
Pediatrician or family doctor:
Date of last physical exam:

MonthDayYear
Date
Describe any significant physical difficulties/illnesses:
Psychological
Examiner’s name:
Date of last evaluation:

MonthDayYear
Date
Results:
Occupational Therapy/Physical Therapy:
Examiner’s name:
Date of last evaluation:

MonthDayYear
Date
Results:
Vision/Hearing:
Date of last examination:

MonthDayYear
Date
Results:
Neurological:
Neurologist’s name:
Date of last examination:

MonthDayYear
Date
Other
IV. Previous Services

Please list any previous therapy or special services your child has received inside or outside of school:
Psychotherapy/Counseling
Dates of service:

MonthDayYear
Date
Provider:
Tutoring
Dates of service:

MonthDayYear
Date
Provider:
Speech/Language
Dates of service:

MonthDayYear
Date
Provider:
Occupational/Physical Therapy
Dates of service:

MonthDayYear
Date
Provider:
Psychiatric
Dates of service:

MonthDayYear
Date
Provider:
Inpatient/Partial Hospitalization
Dates of service:

MonthDayYear
Date
Location of treatment:
Other

Other
Dates of service:

MonthDayYear
Date
Provider:

II. Referral Information

	Yes	Age
Screamed excessively or uncontrollably
Stomped feet
Thrown himself/herself on the floor
Hurt others
Hurt himself/herself
Held his/her breath
Banged head
Expressed concerns about sensory issues