Your Information

Required fields are followed by *.

Parent/Guardian Name *

Email *

Phone *

Parent/Guardian Name *

Email *

Phone Number *

Client Name *

Client Date of Birth *
Day12345678910111213141516171819202122232425262728293031 MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926

Age of Client *
Age in years & months (e.g. 4 years, 2 months)

Client Gender/Pronouns *
Please share with the preferred pronouns of the client. 

Client Address *
123 Peach Street, San Jose, CA 95125

To which schools/programs are you applying? *

Deadline *
If you are not submitting the report for admissions, please input N/A. 

Trouble with eyes/glassesBe sure to bring glasses to assessment

Trouble with ears/hearingPlease forward any audiology reports

Vision and Hearing Notes *
If this does not apply, please input N/A. 

Medications *
Current medications, reason for taking, adverse symptoms, dosage(s), and dates

In what language did your child speak when they uttered their first words? *
Please let us know if the client is still developing their English abilities.

Percentage (%) the client speaks in their native language vs English in the home? *
Please list all language(s) spoken in the home. If English-speaking only, input N/A. 

At what age was your child when they were first exposed to English regularly? *
If English-speaking only, input N/A. 

Has your child received educational instruction in a language other than English? *
yesno

(Educational Instruction other than English) If yes, please explain: *

How much do you feel that your child currently understands in your native language (%) and English (%)? *

Do you feel your child is currently stronger in English or your native language? *
If English-only, input N/A. 

If parents are divorced/separated, list all people who have educational rights for the student *

Educational History *
CURRENT school and CURRENT grade; if attended >1 school please list all school(s) and grade(s). 

Client's Health History *
If this does not apply, please input N/A.

By checking this box and completing registration, I acknowledge that I have reviewed the Treatment Agreement, including confidentiality, HIPAA, and billing disclosures, and understand their ramifications. *View the Treatment Agreement here

By checking this box and completing registration, I understand and agree my child's scores and report will be sent to the school(s) named above. *