Learning Intake Form

STRENGTHS & INTERESTS

GENERAL INFORMATION & HISTORY

Attentional Problems

For each behavior listed below, put a check mark in one of the four columns marked “Not Observed”,
“Mild”, “Moderate”, or “Severe” (see descriptors below)

Not Observed- behavior has not been observed in the past six months.
Mild- behavior occasionally observed in child
Moderate- behavior frequently observed in child
Severe- behavior almost always observed in child

Focused or Selective Attention

Sustained Attention

Shifting Attention

Divided Attention

Divided Attention

Language Functions

For each behavior listed below, put a check mark in one of the four columns marked “Not Observed”,
“Mild”, “Moderate”, or “Severe” (see descriptors below)

Not Observed- behavior has not been observed in the past six months.
Mild- behavior occasionally observed in child
Moderate- behavior frequently observed in child
Severe- behavior almost always observed in child

Articulation

Phonological Processing

Receptive Language

Expressive Language

Speed and Efficiency of Cognitive Processing

For each behavior listed below, put a check mark in one of the four columns marked “Not Observed”,
“Mild”, “Moderate”, or “Severe” (see descriptors below)

Not Observed- behavior has not been observed in the past six months.
Mild- behavior occasionally observed in child
Moderate- behavior frequently observed in child
Severe- behavior almost always observed in child

Processing Speed, Cognitive Efficiency, & Cognitive Fluency

Academic Functions: Reading

For each behavior listed below, put a check mark in one of the four columns marked “Not Observed”,
“Mild”, “Moderate”, or “Severe” (see descriptors below)

Not Observed- behavior has not been observed in the past six months.
Mild- behavior occasionally observed in child
Moderate- behavior frequently observed in child
Severe- behavior almost always observed in child

Reading: Attention Functions

Reading: Phonological Processing & Fluency Functions

Reading: Comprehension/Memory Functions

Reading: Attitudinal Issues

Academic Functions: Writing

For each behavior listed below, put a check mark in one of the four columns marked “Not Observed”,
“Mild”, “Moderate”, or “Severe” (see descriptors below)

Not Observed- behavior has not been observed in the past six months.
Mild- behavior occasionally observed in child
Moderate- behavior frequently observed in child
Severe- behavior almost always observed in child

Writing: Graphmotor output functions

Writing: Spatial Production Functions

Writing: Expressive Language Functions

Writing: Attitudinal Issues

Academic Functions: Math

For each behavior listed below, put a check mark in one of the four columns marked “Not Observed”,
“Mild”, “Moderate”, or “Severe” (see descriptors below)

Not Observed- behavior has not been observed in the past six months.
Mild- behavior occasionally observed in child
Moderate- behavior frequently observed in child
Severe- behavior almost always observed in child

Mathematics: Attention Functions

Mathematics: Computational Knowledge

Mathematical Reasoning/Comprehension

Mathematics: Attitudinal Issues