WesternKentuckyUniversity Literacy Clinic
Application for Clinical Diagnosis of Reading Growth and Development
For Office use only: Date Received ______
Student grade level ______
Please return this form to:
Dr. Nancy Hulan
School of Teacher Education
1083A Gary A. Ransdell Hall
Western Kentucky University,
1906 College Heights Blvd. #61030,
Bowling Green, KY 42101-1030
Office: (270) 745-4324
Fax: (270) 745-6322
1.Child Information: (to be completed by the parent)
Child’s Name:______Birth Date:______M__ F__
Child’s Age:_____Current grade level in school: ______
Present school attending:______
Reason for Referral______
______
______
- Parent Information
Father:______Address:______
Mother:______Address:______
Occupations of Parents: Father______Mother:______
Phone: Home:______Father (work)______Mother (work)______
Cellphones: ______Email Address: ______
Emergency Contact Name: ______
Emergency Contact Phone: ______
Other household members:
NameAgeRelationship
______
______
______
Developmental History Of Child
Has your child experienced any developmental delays? Yes____ No____.
Have there been major illnesses or injuries?____.
If so, what?______
Does your child experience difficulty with: Hearing______Speech______Vision______
Date of most recent hearing screening:______
Results______
Date of most recent vision screening:______
Results______
Does the child wear glasses?______Take any medication?______
What type of medication?______.
Are there recurring illnesses?______.
If so, what?
Allergy______Colds______SoreThroat______Ear ache______
Upset Stomach______Hightemperature______Other______
School History
Present School______Age at 1st grade entrance_____
Present Grade Level______Has child changed schools?______
No. of times______. Was there a problem in adjusting to new situations?______
Was the child retained?______. If so, at what grade level?______.
What subjects does the child like? ______
What subjects does the child dislike?______
General Attitude toward school: Good____Bad____Indifferent____
Is your child working at grade level?______Above grade level?______Below grade level?______
Does the child have an Individualized Education Plan (IEP)? Yes ______No ______
If yes, where is he/she served? (please circle all applicable)
resource roomregular classroomself-containedspeech therapy only
Has your child been absent from school extensively for illness or injury? For other reasons?
______
______
Behavioral History
Does your child get along well with brothers and sisters?______
Does he/she get along well with peers?______
Does he/she get along well with adults?______Favorite adult______
Have you observed that your child differs from others in the following ways?
More sensitive Yes____ No____More aggressive Yes____ No____
More stubborn Yes____ No____More withdrawn Yes____ No____
More fearful Yes____ No____More active Yes____ No____
Is there any other information that you feel would aid us in the evaluation?
______
What other clinical services or special instruction does your child receive?
______
Parent Signature______
Date: ______