New Client Information
Learning Understood LLC
Your Name
First Name
Last Name
Relationship to Child
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child Name
First Name
Last Name
Child Age/Grade
Child Birthday
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current School (if not applicable, please type NA)
What are your main concerns with your child?
Has your child ever been assessed in school or by a psychologist?
Yes
No
Does your child have or has had any the following?
504
IEP
Academic or Behavioral Assessment
Specific Learning Disability
If yes to any, please include any reports, evaluations, records, or notes
Browse Files
Cancel
of
Is your child aware of their challenges?
Yes
No
Has your child ever received one-on-one or small group support for their challenges?
Yes
No
Has your child repeated a grade(s)? If so, which one(s)?
What motivates your child?
What hobbies does your child have?
Please select "yes" or "no" to the following questions
Rows
Yes
No
My child gets all their homework done in a timely manner
My child knows when assignments are due and turns them in
My child knows when and how to ask for help
My child follows multi-step directions
My child writes what they know with ease
My child enjoys reading
My child knows how to show their work in math
My child gets frustrated easily with school
My child understands money and time
My child writes neatly
My child is able to organize thoughts on paper
My child can understand what they read
Our family and home life is affected by school
Is your child on medication?
Does your child wear glasses?
Has your child had a history of ear infections?
Has your child had any head injuries?
My child is easily angered
My child worries a lot
My child is easily distracted
It is difficult for my child to sit still
My child acts on impulse
My child is able to carry on a conversation
My child shares similar interests with other kids his/her age
My child seems unusually focused on any particular situation or topic
How did you hear about Learning Understood?
Submit
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