Evaluation Case History

Date Completed

Date

Individual to be seen*

Home/Primary parent phone*

Sex*

Date of birth*

Date

Address*

Current Grade/Academic Level*

2] If this form is for your child/dependent, please complete this parent section.

If you are an adult completing this for yourself, please skip to #3 below.

Please provide mother’s/guardian’s:

Name

Phone, if different Home phone

E-mail

example@example.com

Fax

[Mother’s] Cell phone

Mothers Ocupation

[Mother’s] work phone

E-mail Cell phone [Father’s]

Please provide the father's/guardian's:

Name

Address, if different

Home phone

Fax

E-mail

example@example.com

work phone

Father's Ocupation

Occupation

3 This case history was completed by Self?/Mother?/Father?/Other?

Who is responsible for payment of bill? *

Let's just hide itWhat is the responsible party’s Social Security Number?*

Whom may we thank for referring you to us?

Please tell us, as completely as possible, why you have contacted Carolyn M. Haar, LLC.*

If completing for a child, are parents married, divorced, separated or single? If a parent is deceased, please indicate which.

If there is a joint custody arrangement for a child, please explain schedule that might affect scheduling sessions with us.

Brothers/Sisters of Individual:

Brothers/Sisters of Individual: Name Age / Sex /School/Grade /Academic Considerations

The primary language spoken in the home? Is this your/this student’s first language this individual learned?

Is there any other important family history/information we should consider?

Please note any significant birth/adoption, pregnancy, developmental, speech/language, and/or medical history/concerns.

Is there any history of seizures/seizure disorder? If yes, please describe here.

Is the individual being seen currently under special or regular care of a physician?

Currently taking any prescription medication(s)*? If yes, please explain.

If prescription medication is taken currently for attention/other purposes, it SHOULD BE taken on the day of the testing and/or during tutoring as prescribed.

When was the last hearing test ?

When was the last eye examination?

Are there any sleeping difficulties? If yes, please explain

Average length of sleep per night?

Is there regular napping?

Are there any eating difficulties? If so, please describe on line below.

At approximately what age was left/right hand chosen?

Are you aware of any difficulty with focusing or paying attention? If yes, please describe as thoroughly as you can.

Do you, or does anyone, feel there is an unusual activity level? describe as thoroughly as you can.

Have you or others noted any unusual behaviors? If yes, please explain

Have there been any recent changes in behavior? If yes, please explain

Is there difficulty with discipline or authority? If yes, please explain

Does individual react to textures, food, or smells in a ways that seems unusual to you orothers?

Is this individual socially-appropriate with peers?

Is individual appropriate/comfortable with those in authority?

Please list interests and involvement outside of school/academics/work.

Does individual spend more time alone or with other people? Please describe.

Please describe self-esteem and confidence. Is this different related to school/work compared with other activities and interests?

Please list all schools attended from preschool through the present. Include years, difficulties, and any assistance/accommodations received.

School Name

Remediation/Accommodations

Was there a skipped or repeated grade? If yes, please tell when and why.

Please list current or upcoming professors/teachers and subject areas if currently enrolled.

Teacher/Professor

Subject

Teacher/Professor

Subject

Teacher/Professor

Subject

Teacher/Professor

Subject

Teacher/Professor

Subject

Teacher/Professor

Subject

Please tell us two academic subjects/areas individual finds typically most challenging.

What is this individual’s feeling about/toward school/teachers/professors or work?

Please describe study habits/work habits, organization, time usage, and motivation/effort.

Have any other professional evaluations* been completed? Please list any educational consultations, psychological/psychiatric evaluations, medical tests, or other evaluations that have been conducted.*

If there is any other information you feel would be helpful that you can share with us so that we can be more helpful to you, please feel free to do so below. Please do not write on the back of this page. You may add a page if helpful.

Carolyn M Haar, MS CCC LLC CONTRACTUAL AGREEMENT & RELEASE FORM

Tutorial service two times per week, a minimum start-up schedule, allows providers to develop study approaches in one or two subjects simultaneously. If three subjects are to be targeted, a three hour per week minimum is required. [It is not feasible to develop three subjects in less time. If modifications are still in order due to your child’s needs, Carolyn M Haar will discuss this with you.]
Billing for services is sent on a monthly basis. All contractors bill Carolyn M Haar, MS CCC LLC by the last day of each month, and invoices are emailed within 2 days to you. Payment is made from your credit card on the 7th or 8th of each month. This allows our contractors to be paid in a timely fashion.
If a student is scheduling for exam preparation only, without having been seen regularly during the previous semester, anticipated estimated payment is due in advance of sessions. You will be billed prior to beginning this service.
If the credit card on file is denied and not able to be reconciled within 48 hours, a $15 delinquent fee will be assessed.
NSF checks for evaluations are charged $35.00. Subsequent payment for an evaluation is to be made by certified check or credit card.
If reimbursement to you from insurance is possible, we are happy to help you complete insurance forms. However, payment is due directly from you so that we can honor our agreement with your contractor.
Brief family/professional contact by phone or email with Carolyn M Haar is included in our service as a courtesy. If longer than 15 minutes, these contacts are charged by time at provider’s rate. Site visits (on campuses, in other professionals’ offices, at your home) are billed by time at the rate of the provider.
Your provider is asked to spend the last few minutes of each session speaking with you, to review work or suggestions prior to the next regularly scheduled session. If there is a need for additional conference time with your provider, you are asked to schedule a separate session. This is billed by time. Alternately, feel free to contact Carolyn M Haar with questions or concerns.
If you are a parent or guardian, we respectfully request that you refrain from confrontation with your child [or between parents] in the presence of your child when speaking with your provider. Serious matters should be discussed separately, typically appropriately without your child present. Please feel free to call Carolyn M Haar for this purpose.
Any services that are charged by time other than your regular sessions are scheduled only with your permission and/or upon your request. Such services are charged according to the rate of your provider or the providing the service. These may include, but are not limited to, classroom observations and professional conferences.
Providers may not assume or provide additional time outside of that upon which you have mutually agreed without your permission or request. Your provider(s) may request additional time as needed (such as at exam time), but this time will not be assumed or provided without your consent.
Please know that each provider is responsible to Carolyn M Haar to discuss and/or determine significant decisions/changes in programming on behalf of you/your child(ren). You may also contact Carolyn M Haar to discuss concerns or to request changes.
Cancellations for scheduled Intakes and tutorial sessions must be made with 24- hr. notice to avoid being charged. Broken appointments will otherwise be charged based on the full rate of sessions. Please notify your provider(s) of vacations, field trips, school closings/holidays, etc. *Without 24-hour notice, a broken appointment fee equal to the charge of session will be charged to compensate provider for time reserved for you. Please notify us of emergencies.
We ask that at least one parent/responsible adult be present during sessions in your home. Exceptions to this policy can only be made with prior written consent. Please call our office to request a form for this purpose if needed. *Note: Tutors may not remain in your home without parent or other responsible adult present or without written consent. They are asked to leave in this situation; the session is charged at the regular rate to allow the tutor to be compensated for your reserved appointment time.
If you require duplicate billing (i.e., two separate copies of billing to two addresses or a duplicate invoice for tax purposes), a $35 fee per monthly invoice is assessed, payable in advance of records being sent.
Please be at home and on time for scheduled sessions. As a courtesy to you, we ask our providers to wait up to 15 minutes if you are not present if he/she is comfortable in doing so. This time is then included as a part of your regularly scheduled appointment time if you arrive late. Your provider will leave if you are not available after 15 minutes and will notify Carolyn Haar. We then will attempt to contact you. Scheduling to make up time missed on behalf of you/your child is recommended and will be offered based on your provider’s availability.
We extend to each individual and family with whom we work a commitment to provide a productive and positive program. Our years of experience prove that consistency and dedication from students, families, and providers is an ideal combination!

Carolyn M. Haar, MS CCC LLC-RELEASE FORM

Please complete all applicable sections. The lines marked by an X are required. I authorize Carolyn M. Haar, MS CCC LLC to provide services for the person named below. These services may include an tutorial/remedial services, conferences, classroom/other observations, screenings, and/or reports. Services may be scheduled upon my request and/or with my permission. I have read the Carolyn M. Haar, MS CCC LLC Contractual Agreement. My ELECTRONIC PRINT or E-SIGNATURE means I understand and agree.

Name of individual to be seen *

Signature*

Date*

Date

Relationship (Parent/Guardian/Self)*

I authorize Carolyn M. Haar, LLC to exchange verbal or written information with others concerning the person listed, including teachers, professors, administrators, physician, amd/or counselors, upon my request and/or permssion. My ELECTRONIC PRINT or E-SIGNATURE means I understand and agree to provide this service.

Signature*

Date

Relationship (Parent/Guardian/Self)*

Evaluation Case History

FAMILY HISTORY & REASON FOR CONTACT

EDUCATIONAL HISTORY

IN CONCLUSION