EmailMe Form - EXCEPTIONAL STUDENT EDUCATION

EmailMeForm

(Please fill out the form in its entirety so that we can better serve you and your student.)
Student Name *
First Last
Student Current Grade
Is your child homeschooled?
Yes
No
Name of your child's current school:
Interested in enrolling when?
Parent/Guardian Name *
First Last
Parent/Guardian Name *
First Last
Email *
Phone *
### - ### - ####
Diagnosis
Most recent testing date (Must be within the last 3 years or new testing will be required.)
Does your child have a current IEP? (A copy will need to be provided with school application.)
Yes
No
Current Level of support/setting:
Separated/Self-contained
Resource/Pull-out
Inclusion/Push-in
What are your child's strengths?
At or above grade level in reading
Organized and has reasonable study skills
At or above grade level in writing
Minimal off-task or problematic behaviors
At or above grade level in math
Works well independantly
Communicates fluently with use of verbal language
What are your concerns/needs in Language Arts?

Writing Skills Vocabulary Decoding Skills Reading Comprehension

Language Arts
What are your concerns/needs in Math?

Basic Math Facts Computation Applied Problem Solving Word Problems

Mathematics
What are your concerns/needs in Communication?

Expressive Language Delays Receptive Language Delays Non-verbal

Communication
Does your child have any medical needs or on medication?

Diagnosed Medical Condition Diagnosed Mental Health Condition Takes Medication

Health/Medical
Please list medical, mental health, or other health info/diagnosis below:
What are your concerns/needs in Motor Skills?

Gross Motor Coordination Fine Motor Coordination Sensory Support

Motor Skills
Please describe sensory needs/aversion:
What are your child's areas of concern/needs in daily living skills?

Toileting Dressing Self Feeding Self Communicating Basic Wants/Needs Safety Awareness Understanding Social Cues

Daily Living Skills
Does your child have any behavioral/social concerns?
Noncompliance
Low Motivation
Overactive
Off-task
Difficult to Redirect
Verbally Aggressive
Physically Aggressive
Fearful/Anxious
Elopes (Runs or walks away)
Ritualistic/Repetative Behaviors
Poor Social Boundaries
Engages in Self-stimulation (Stimming)
What are your child's areas of concern/needs in study/work skills?
Disorganized
Making Transitions
Avoids Difficult Task
Following Directions
Completing Task
Remaining In Seat
Screams or Yells Frequently
Does Not Work Independently
Changes in schedule/routine
Please tell us any other concerns or needs your child has that would help us meet the academic needs of your student in the classroom.
Parent Priorities:

	Writing Skills	Vocabulary	Decoding Skills	Reading Comprehension
Language Arts

	Basic Math Facts	Computation	Applied Problem Solving	Word Problems
Mathematics

	Expressive Language Delays	Receptive Language Delays	Non-verbal
Communication

	Diagnosed Medical Condition	Diagnosed Mental Health Condition	Takes Medication
Health/Medical

	Gross Motor Coordination	Fine Motor Coordination	Sensory Support
Motor Skills

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	Toileting	Dressing Self	Feeding Self	Communicating Basic Wants/Needs	Safety Awareness	Understanding Social Cues
Daily Living Skills