IHE Application

Application
Parent Name

First NameLast Name
Phone Number

Area CodePhone Number
How did you hear about us?*
Referring child or parent’s name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County
Student Name

First NameLast Name
Grade Level
Thank you for taking the time to fill out this information concerning your child. Your answers will only be used to help IHE get to know your student and help formulate a plan for success!
List anything your student been diagnosed with medical or learning differences that are impeding on his/her learning in a conventional classroom setting? (example: ADHD, Dyslexia, executive function deficit, etc.)
What are your academic goals for your child?
Does your student have an IEP or 504?
What are your student’s current grades in each subject?
Lang. Arts (A,B,C,D,F) Math (A,B,C,D,F)

History (A,B,C,D,F) Science (A,B,C,D,F)
Does your student currently or in the past received any type of interventions?

Speech TherapyOccupational TherapyPhysical TherapyIntense ReadingIntense MathApplied Behavior TherapyFeeding TherapySocial Skills TherapyLanguage Therapy
How would you rate your child in these areas? (1= Never, 2= Rarely 3= Sometimes 4=frequently) If you do not know an answer, simply leave it blank.

Asks to have stories read to him/her.

	1	2	3	4

1 is Never, 4 is Frequently

Enjoys listening to you or the teacher at school read.

	1	2	3	4

1 is Never, 4 is Frequently

Initiates reading on his/her own at home.

	1	2	3	4

1 is Never, 4 is Frequently

Gets absorbed in a book (or a book series such as Harry Potter).

	1	2	3	4

1 is Never, 4 is Frequently

Discusses books he/she has read with you.

	1	2	3	4

1 is Never, 4 is Frequently

Has listened to audio books

	1	2	3	4

1 is Never, 4 is Frequently

Reads a book aloud to an adult

	1	2	3	4

1 is Never, 4 is Frequently

List any special interests your child has. This can assist me to find books/articles with subjects that appeal to your child. (example: loves sports, video games or dinosaurs)
List the strength(s) your child has as a reader (example knows all his sight words)
List the weakness(es) your child has as a reader. (example struggles with comprehension, fluency, does not enjoy reading)
Is your child taking any medication? _______ If yes, please list type and when they take it
Is your student allergic to any foods ? No or If Yes Explain
Does your student have access to a computer on a daily basis?
Social Skills

Are social skills in the classroom impeding learning? How would you rate your child in these areas? (1= Never, 2= Rarely 3= Sometimes 4=frequently) If you don’t know an answer, simply leave it blank.

Has someone he/she calls her friend

	1	2	3	4

1 is Never, 4 is Frequently

Sits and talks with peers at lunch

	1	2	3	4

1 is Never, 4 is Frequently

Starts a conversation with a peer that is new

	1	2	3	4

1 is Never, 4 is Frequently

Listens to a peer and responds appropriately

	1	2	3	4

1 is Never, 4 is Frequently

Takes turns listening and talking to peers

	1	2	3	4

1 is Never, 4 is Frequently

Cheats in games or breaks rules or makes up own rules while playing game

	1	2	3	4

1 is Never, 4 is Frequently

Purposely irritates others

	1	2	3	4

1 is Never, 4 is Frequently

Argues with others

	1	2	3	4

1 is Never, 4 is Frequently

Takes responsibility for own actions

	1	2	3	4

1 is Never, 4 is Frequently

Engages in attention seeking activities in class (taps pencil, falls out of chair, says funny things to get other to laugh)

	1	2	3	4

1 is Never, 4 is Frequently

Independent work habits

How would you rate your child in these areas? (1= Never, 2= Rarely 3= Sometimes 4=frequently) If you do not know an answer, simply leave it blank.

Completes homework all on their own

	1	2	3	4

1 is Never, 4 is Frequently

Can’t find homework or necessary supplies to complete work

	1	2	3	4

1 is Never, 4 is Frequently

Waits till the last minute to complete assignments

	1	2	3	4

1 is Never, 4 is Frequently

Hands assignments in on time

	1	2	3	4

1 is Never, 4 is Frequently

Studies for exams

	1	2	3	4

1 is Never, 4 is Frequently

Asks for help when he/she does not understand a concept or instruction

	1	2	3	4

1 is Never, 4 is Frequently

Looks for additional resources to help understand a skill or concept (uses dictionary.com, notes or a number chart)

	1	2	3	4

1 is Never, 4 is Frequently

Please list any additional information about your student that you feel would help in creating an educational plan for success!
Should be Empty:

Application

What are your student’s current grades in each subject?

How would you rate your child in these areas? (1= Never, 2= Rarely 3= Sometimes 4=frequently) If you do not know an answer, simply leave it blank.

Social Skills

Independent work habits