Parent Input Form

Date *

Your Name (Parent/Guardian) *

Child's Name *

Home Language(s) *

How do you support your child at home? (e.g., homework help, reading together, tutoring) *

List two or three things your child enjoys in their free time (activities, characters, items, etc.): *

List two or three positive words that describe your child: *

How does your child learn best at home? (Choose all that apply) *

Visual (things they see or read) Auditory (things they hear or listen to) Kinesthetic (hands-on)

Please describe any known family history of disability or difficulty in school. If none, write N/A. *

Brothers/sisters living in the home (name and age):

Other individuals living in the home (name, relationship, age):

Have any significant life events or changes occurred in the past three years? If so, please explain how this may have affected your child.

Do you have any concerns regarding your child's communication or speech? *

Yes No

At what age did your child begin speaking single words? *

At or before 12 months 12–18 months After 18 months Not sure

At what age did your child begin speaking 4–5 word phrases? *

At or before 18 months 18–24 months After 24 months Not sure

At what age did your child begin speaking complete sentences? *

Under 3 years 4–5 years Over 5 years Not sure

Child's birth weight *

Current age *

Were there any difficulties during pregnancy or delivery? If yes, please describe.

Were there any difficulties at birth? (e.g., cyanosis, jaundice, seizures, breathing difficulties)

What time does your child go to bed? Do they have difficulty falling or staying asleep?

Please list any hospitalizations or surgeries your child has had:

At what age did your child sit up independently? *

Before 6 months 6–9 months After 9 months Not sure

At what age did your child begin walking independently? *

Before 12 months 12–18 months After 18 months Not sure

At what age was your child potty trained? *

12–24 months 2–3 years After 3 years Not sure

Do you have concerns regarding your child's fine or gross motor skills? *

Yes No

Please note any current health problems or conditions that may impact your child's educational performance: *

Does your child currently take medication? If so, please list the medication name and the condition it treats:

Do you have concerns regarding your child's behavior? *

Yes No

Describe your child's overall attitude toward school: *

What makes your child frustrated or angry? *

Do you have concerns regarding your child's academic performance? *

Yes No

Did your child attend preschool? *

Yes No

Has your child ever been retained (held back a grade)? *

Yes No

Has your child received outside tutoring or in-school academic supports? *

Yes No

If yes, please describe the type of support and how long it was provided:

Using the scale below, please rate your child's skills in each area. Mark only one rating per row.

Scale: 1 — Major concern 2 — Some concern 3 — Average 4 — Above average 5 — Significantly above average

Communication	1 Significantly Below Average (major concern)	2 Below Average (some concern)	3 Average (no concern)	4 Above Average	5 Significantly Above Average

Speech Intelligibility / Pronunciation of Sounds
Voice Quality
Comprehension of Word Meanings
Following Oral Instructions
Comprehension of Discussions
Remembers Information Just Heard
Use of Adequate Vocabulary
Use of Adequate Grammar for General Understanding
Expresses Self Fluently When Called On to Speak
Relates a Sequence of Events in Order (telling a story)
Organizes and Relates Ideas and Factual Information
Use of Socially Appropriate Language
Able to Express Needs and Wants

Adaptive Behavior	1 Significantly Below Average (major concern)	2 Below Average (some concern)	3 Average (no concern)	4 Above Average	5 Significantly Above Average

Takes Care of Own Belongings
Does Age-Appropriate Chores
Dresses and Bathes Self
Orders Own Food at a Restaurant
Helps Out at Home
Cares for Personal Hygiene
Cleans Up After Self
Works Independently on Own Projects

Academic Skills	1 Significantly Below Average (major concern)	2 Below Average (some concern)	3 Average (no concern)	4 Above Average	5 Significantly Above Average

Basic Reading Skills (letter names and sounds, decoding new words)
Reading Fluency (reads smoothly and at an appropriate pace)
Reading Comprehension (understands what is read)
Written Expression / Writing
Handwriting
Math Calculation
Math Problem Solving (word problems)
Listening Comprehension
Spelling

Reading, writing, math, and language are each made of separate skills, like strands in a rope. Check the parts that are hardest for your child. Leave blank anything you are not sure about. The gray name in parentheses is the term you will see in the evaluation report.

The Reading Rope

Language Comprehension

Background Knowledge — what they already know about the worldVocabulary — knowing what words meanLanguage Structures — understanding how sentences workThinking Through Text (Verbal Reasoning) — thinking through what they readHow Books Work (Literacy Knowledge) — how books and print work

Word Recognition

Hearing Sounds in Words (Phonological Awareness) — hearing and manipulating sounds in words, including individual speech sounds (phonemes)Sounding Out Words (Phonics) (Decoding (Phonics)) — sounding out unfamiliar words through phonics patterns and word structureRecognizing Words Instantly (Sight Word Recognition (Orthographic Mapping)) — recognizing common words instantly

The Writing Rope

Text Generation

Oral Language — grammar, vocabulary, and sentence structurePlanning & Organization — organizing ideas before and during writingReading Skills — reading ability supports writing development

Transcription

Spelling — putting letters together correctlyRemembering Letter Forms (Orthographic Processing) — storing and retrieving letter forms and spelling patterns from memoryForming Letters by Hand (Graphomotor Function) — motor planning and execution of letter productionWriting Speed & Automaticity (Writing Fluency & Automaticity) — producing written language at rate without conscious effort

The Math Rope

All Strands Intertwine

Number Sense — understanding what numbers mean, how they compare, and how they relate spatiallyMath Fact Fluency (Fact Fluency) — recalling math facts quickly and automaticallyKnowing the Steps (Procedural Knowledge) — knowing the steps to solve problemsUnderstanding the Why (Conceptual Understanding) — understanding the "why" behind mathMath Reasoning (Mathematical Reasoning) — applying math to word problems and real life

The Language Rope

Receptive Language

Vocabulary — knowing what spoken words meanUnderstanding Sentences (Sentence Comprehension) — understanding how spoken sentences fit togetherReading Between the Lines (Inferencing) — understanding what is implied but not said

Expressive Language

Finding Words (Word Retrieval) — finding the right words to sayBuilding Sentences (Sentence Formulation) — putting words together to express ideasTelling Stories (Narrative & Discourse) — telling organized stories and explanationsSocial Language (Pragmatics) — using language appropriately with others

What does your child do when something on this list is hard? (e.g., gives up, guesses, asks for help, gets upset)

Please share anything else you would like the evaluation team to know about your child: