CRSD Background Information

BACKGROUND INFORMATION FORM

NOTE: ONLY COMPLETE THIS IF YOU HAVE SIGNED/APPROVED A PRIOR WRITTEN NOTICE FOR INITIAL EVALUATION (OR REEVALUATION) AND REQUEST FOR CONSENT FORM. IF YOU ARE NOT SURE, PLEASE CONTACT THE SCHOOL TO CONFIRM. PLEASE ALSO NOTE THAT NOT ALL FIELDS ARE REQUIRED!
I. Demographics:
Student Name*

First NameLast Name
Date of Birth:

MonthDayYear
Grade*
Grade*
School*
Current Teacher(s)*
Parent Completing Form*

First NameLast Name
Phone Number*

Area CodePhone Number
E-mail*
Note: For you to receive a copy of your form once completed, this field have a valid email. If you do not immediately see your emailed copy, please check your junk or spam folder.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

III. Family History
In whose home does the child live?

Natural Parent(s)Foster Parent(s)Adoptive Parent(s)Другой
Since birth, how many homes has your child lived in?
Reason for moving?
Name of Mother:
Date of Birth:
Highest Level of Education:
Occupation:
Place of Employment:
Does Mother Live at Home?

YesNo (See below)
If no, amount and type of contact with child?
Name of Father:
Date of Birth:
Highest Level of Education:
Occupation:
Place of Employment:
Does Father Live at Home?

YesNo (See below)
If no, amount and type of contact with child?
Number of Siblings? (List Below)
Name:
Age
Living at home?
School/Grade or Occupation
Name:
Age
Living at home?
School/Grade or Occupation
Name:
Age
Living at home?
School/Grade or Occupation
Name:
Age
Living at home?
School/Grade or Occupation
Name:
Age
Living at home?
School/Grade or Occupation
Please list others living in the home and describe relationship to child:
What activities does the family do together?
What is the primary language spoken in the home? Any others?

VIII. School History
If your child attended preschool, please list the years and places he/she attended
Please list other schools your child has attended. Please also indicate when and their experience:
Describe the child's attitude and motivation towards school:
Please describe any previous school problems:

IX. Additional Information
How is the child disciplined?
Other upsetting events and/or significant losses in the life of the child or the family (explain
Has the child received any educational or psychological testing, therapy, or remediation?*

Yes (Please describe below)No
If yes, please provide details:
If you would like to share any reports regarding the above, please upload here:

Upload a File

Cancelof
Would you feel comfortable authorizing the Council Rock School District, through the Department of Special Services, to obtain from/release to and communicate with the provider(s) described above?*

YesNo
Please click link below and complete form

CRSD Parent Authorization (Release)
Is there any additional information you would like to include to assist with this evaluation?
At the conclusion of the evaluation, a meeting will need to be held to review the findings and/or what the next steps are. Starting at least 45 days from today's date, please select three dates and times (between 8am and 3pm) below.
Meeting Date/Time:

MonthDayYear
DateHourMinutesAM/PM Option
Meeting Date/Time:

MonthDayYear
DateHourMinutesAM/PM Option
Meeting Date/Time:

MonthDayYear
DateHourMinutesAM/PM Option
We will do our best to accommodate the above dates and will confirm with you before we meet. Please do not appear without having first received confirmation. If any adjustments need to be made, please contact us.
Should be Empty:

BACKGROUND INFORMATION FORM