Special Education Assessment Form- Greenzone Academy Management System

Special Education Assessment Form

Thank you for your interest in hiring tutors from Greenzone Academy! Please take a few minutes to fill out this pre-assessment form to help us understand your child(ren)’s needs. Your answers will guide us in pairing your child with the best-fit recommendation and tutor(s).

Section A: Basic Information

1. Child’s Full Name *

2. Child’s Current Age (e.g., 5 years 4 mths.) *

3. Child’s Gender *

4. Is your child currently enrolled in a school? *

7. Have you noticed any delays in your child’s development compared to peers? *

Section B: Medical & Developmental History

8. Was your child born full-term or preterm? *

9. Were there any birth complications? *

10. At what age did your child start walking? (in months or years)

11. At what age did your child say their first words? (in months or years)

12. Has your child been diagnosed with any medical condition(s)? *

13. Has your child ever been assessed by a specialist (e.g., pediatrician, psychologist)? *

14. Does your child have hearing or vision challenges? *

15. Is there any family history of developmental disorders (e.g., Autism, ADHD, Dyslexia)? *

Section C: Speech & Communication

16. Does your child speak clearly and in full sentences? *

17. Does your child have difficulty expressing thoughts or needs? *

18. Does your child follow instructions easily? *

19. Does your child engage in conversations with others? *

20. Does your child repeat words or phrases frequently? (echolalia) *

21. Has your child ever received speech or language therapy? *

Section D: Behavior & Attention

22. Does your child have trouble staying focused on tasks? *

23. Is your child easily distracted or hyperactive? *

24. Does your child struggle to sit still for long? *

25. Does your child engage in repetitive behaviors (e.g., hand flapping, rocking)? *

26. Does your child get upset with changes in routine? *

27. Does your child have frequent emotional outbursts or tantrums? *

Section E: Learning & Academics

28. Does your child struggle with reading, writing, or spelling? *

29. Does your child mix up letters or words while reading? *

30. Can your child complete academic tasks independently? *

31. Has the school raised concerns about your child’s academic performance? *

32. Have you personally noticed any learning difficulties? *

Section F: Support & Interventions

33. Has your child been formally assessed for Autism, ADHD, Speech Delay, or Dyslexia? *

34. What kind of support has your child received so far?

Speech therapy

Occupational therapy

ABA therapy

Special education support

None

35. Are you currently working with any specialists or support professionals? *

36. What improvements have you noticed (if any)?

37. What are your top 3 concerns about your child right now? *

38. What are your child’s strengths or areas of interest? *