I. To Be Completed By Parents: ATLANTA SPEECH SCHOOL CHILD: BIRTHDATE SCHOOL: DATE: GRADE: My child is applying for services at the Atlanta Speech School. You have my permission to fill out the following questionnaire, send requested data, and talk with specific Speech School personnel in advance of my child s appointment to clarify presenting concerns. Parent or Guardian II. To Be Completed By Advisor and/or Principal and Teachers: A. We are greatly assisted in evaluation and/or placement by comments and data from the child s school. Please help us by mailing to us as much of the following data as possible. We appreciate your time and effort in gathering materials and completing this form. 1. Previous educational test data. 2. Reports and/or comments of previous and present teachers. 3. Progress reports from special programs such as speech therapy, individual tutorial help. 4. Illustrative samples of work when pertinent. B. Do you have concerns about this child? YES or NO If so, what are your major concerns? What is your opinion of this child s self-esteem. Describe typical classroom behaviors: Please comment on any electives or extra-curricular activities. School: Phone Number: Date this questionnaire completed: Signed: Title:
for: Child s Name ENGLISH/LANGUAGE ARTS/LITERATURE Oral Language Contributes to group discussion Understands classroom instructions Learns and uses new vocabulary Expresses ideas well orally Uses good grammar orally Pronounces words correctly Reading Interprets and applies what is read Understands abstract language (i.e. metaphors)
Written Language Is able to express ideas clearly Uses punctuation and capitalization Writes in complete sentences Uses imagination in creative writing Writes pieces of adequate length Can organize research projects Has sense of audience YES No Handwriting Forms letters correctly Spaces letters and words appropriately Demonstrates adequate handwriting speed Is required to use manuscript/cursive for classwork (circle one) Is competent with keyboarding Spelling Uses phonetic rules Sequences correctly (ex. dress/drsse) Revisualizes non-phonetic words (ex. what, was) Spells correctly in free composition Date this questionnaire completed: Signed: Title:
for: (Child s Name) MATHEMATICS (Pre-Algebra, Algebra Geometry, Trigonometry, Calculus) (Please circle the appropriate curriculum) Comments: Understands general mathematical concepts Computes with reasonable speed and accuracy Is able to solve problems Completes daily homework assignments Practices self-discipline Date this questionnaire completed: Signed: Title:
for: Child s Name SCIENCE (Physical Science, Biology, Chemistry, Physics) (Please circle the appropriate curriculum) Comments: Understands concepts Retains facts and terminology Participates in class Demonstrates knowledge on tests Demonstrates responsibility for homework and extra projects Date this questionnaire completed: Signed: Title:
Middle/High School Questionnaire For: Child s Name Social Studies (Economics, Political Science, History, Sociology, Geography) (Please circle the appropriate curriculum) Comments: Understands concepts Retains facts and terminology Participates in class Demonstrates knowledge on tests Demonstrates responsibility for homework and extra projects Practices self-discipline Date this questionnaire completed: Signed: Title:
Middle/High School Questionnaire For: Child s Name Foreign Language (French, Spanish, Latin, German) (Please circle the appropriate curriculum) Comments: Comprehends and retains vocabulary and grammatical structure Participates in class Demonstrates knowledge on tests Pronounces words correctly Date this questionnaire completed: Signed: Title: