FORM 5 School Bridge Questionnaire

School Bridge LLC 1489 Chain Bridge Road, Suite 203, McLean, Virginia 22101 703-728-8676 www. testingld.com

Confidential Intake Questionnaire
Student Personal Information
Student Name (first, middle, last)
Date of birth

MonthDayYear
Date
Current Age
Current Grade
Client Address
Phone Number
GUARDIAN
Primary guardian of the student (if minor)? Parent/s or other
Mother/Parent
Mother Name (first, last)
Mother Cell
Mother's Email
Mother Address
High School (Name, State); University (Name, Degree); Graduate School (Name, Degree); Occupation; Current Employer
Father/Parent
Father Name (first, last)
Father Cell
Father's Email
example@example.com
Father Address
High School (Name, State); University (Name, Degree); Graduate School (Name, Degree), Occupation; Current Employer
SIBLINGS
Sibling/s (Name, Age, School)
Step-sibling/s (Name, Age, School)
Half-sibling/s (Name, Age, School)
Parent Marital Status
Parents?
Married
Separated (year?)
Divorced (Year?)
Widow/er (Year?)
Custody arrangement? Who has it? Sole? Shared?
Stepparents
Stepfather name
Married (Year?)
High School (Name, Location)
College (Name, Degree)
Graduate School (Name, Degree)
Occupation
Current Employer
Stepmother Name
Married (Year?)
High School (Name, Location)
College (Name, Degree)
Graduate School (Name, Degree)
Occupation
Current Employer
Home
Whom does the student live with currently?
What language/s spoken in the home?
Previous address/es
A grandparent, nanny, any others living in the home? Or nearby (live-out) who helps to care for the student consistently? (Name, role)
Developmental
Birth full term or preterm?
Any complications during pregnancy?
Any complications during birth and delivery?
Baby temperament? (Easy, typical, difficult)
Toddler temperament? (Easy, typical, difficult)
Physical milestones: sit, crawl, walk (on time, early, late)
Expressive language: utterances, words, sentences milestone (on time, early, late)
Toilet training? (On time, early, late)
Bedwetting? Until what age?
Right or left-handed
Able to ride a bike? Age?
Handwriting? (typical, atypical, describe)
Family History
Learning disability Who? What?
Autism/Aspergers (Who? What?)
Cognitive Impairment or Low Functioning (Who? What?)
Mood disorder (depression, OCD, other) Who? What?
ADHD? Who? What?
Anxiety? Who? What?
Substance abuse? Who? What?
Other issues? Who? What?
MEDICAL
Primary care doctor (Name, Location)
Other medical doctors? (Name, Location)
Therapist? (Name, Location, Year)
Current health? (excellent, typical, atypical, describe)
Weight (typical, not typical, describe)
Height (typical, not typical describe)
History Injuries?
History Illnesses?
History Hospitalizations?
Current medications? (What? Why? Dose)
Past medications? (What? Why? Dose)
Respiratory
Allergies
Asthma
Other conditions?
History of ear infections?
Hearing ok?
Tubes? (Year) (Doctor)
Tonsils removed? Adenoids? Date?
Vision ok?
Glasses? Contacts?
Strabismus history?
Digestive
Colic as a baby?
Stomach aches?
Digestive concern? Considerations? Diagnosis? Chrons, IBS, other.
History of constipation or withholding?
History of eating disorder?
Eating patterns? (typical, not typical, describe)
Any changes in eating recently?
Head
Seizures? (Date)

MonthDayYear
Date
Concussions? (Year, Grade/Age, Cause, Symptoms)
Sleeping
How many hours sleep per night?
Falling asleep (easy, typical, difficult)
Staying asleep (easy, typical, difficult)
Waking (easy, typical, difficult)
Other concerns regarding sleeping?
Personality
Traits? Temperament?
Strengths?
Ability to initiate, maintain friendships with peers?
Ability to initiate, maintain friendships with adults?
Concerns?
Interests
Hobbies? Interests?
Sports? Athletics?
Music? Dance? Art?
Service, outreach, volunteer?
Videogame activity (typical, atypical, N/A Describe)
Phone use (typical, atypical, N/A Describe)
Interest in cooking, baking, sewing, building, fixing?
Other Activities? Clubs?
Hiking? Biking? Swimming?
Interest in reading for pleasure?
Summer camp? (location, year)
Accolades, awards, recognition?
Related Services
Speech and language therapy?
Vision therapy? (Dates, Provider Name, Location)
Psychological, emotional therapy? (Dates, Provider Name, Location)
Occupational therapy? (Dates, Provider Name, Location)
Tutoring
Instructional support (Name of a tutor, Year, Location)
Effective?
Previous DX
Previously diagnosed with ADHD? (date, by who)
Anxiety? (date, by who)
Learning disorder? Reading? Writing? Math? Other? (date, by who)
Mood? (date, by who)
Any other dx?
School Placements
Preschool (name, location, years)
Elementary school (name, location, years)
Middle school (name, location, years)
High School (name, location, years)
Undergraduate school (name, location, years)
Graduate school (name, location, year)
Educational Services
Special education services? History of 504 plan? IEP? School Learning Plan? (Year/s? Year Started, County or School Name)
History of Accommodations
History of accommodations? (What? Year/s? Started, County or School Name, in Classroom? On standardized tests?)
PROVIDED TO SCHOOL BRIDGE/DR MUIR
Report card, progress report?
Previous educational evaluation?
Transcripts?
Previous standardized test scores?
IEP, 504, School learning plan
DISCIPLINE
Any behavioral or discipline concerns at home? (What, when)
Any behavioral or discipline concerns at school? (What, when)
Suspension? Expulsion? (Year, Why)
Any police investigation? Charge? Outcome? (Year, Why)
Drug, vape, tobacco alcohol, other substances? (What, when)
EMPLOYMENT HISTORY
(List any job experience, position, location)
Primary Presenting Challenge/S
Reading? Writing? Math? Listening? Speaking? Attention? Anxiety? Organization? (Identify and describe)
Goals of Evaluation?
What do you consider is the primary goal of the evaluation?
ANYTHING ELSE WE SHOULD KNOW?
Who referred you to us for services?
Should be Empty:

Student Personal Information

GUARDIAN

Mother/Parent

Father/Parent

SIBLINGS

Parent Marital Status

Stepparents

Home

Developmental

Family History

MEDICAL

Respiratory

Digestive

Head

Sleeping

Personality

Interests

Related Services

Tutoring

Previous DX

School Placements

Educational Services

History of Accommodations

PROVIDED TO SCHOOL BRIDGE/DR MUIR

DISCIPLINE

EMPLOYMENT HISTORY

Primary Presenting Challenge/S

Goals of Evaluation?