School Age Child Educational Questionnaire

Tri-State Developmental Pediatrics

Please correct the errors described below.

Your student has been referred to Tri-State Developmental Pediatrics for evaluation or treatment. Thank you in advance for completing the following form. Information and input from your team is very important to us! Diagnostic and treatment decisions rely on an understanding of a child’s functioning in a variety of settings. We also rely heavily on school-based standardized testing and formal psychoeducational testing. We do not repeat any testing that is completed at school. Before scheduling a child’s evaluation, we ask the family to collect educational records and appreciate when schools make these records available to families.

Child Information

School Information

Current Academic Functioning

Please indicate whether you have concerns about the child’s functioning in each of the following areas. Please elaborate on your areas of concerns

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