Re-Assessment Parent Questionnaire
Your child is being re-evaluated by one of or all of their therapists. During a re-evaluation we update medical information, retest with standardized assessment tools and other objective measures, review goals and overall needs. We need your help to keep our information accurate and current. Please answer the questions below so we can keep your child’s information current and address all concerns you may have for your child.
Child's Name
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First Name
Middle Name
Last Name
Date of Birth
*
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Month
-
Day
Year
Date
List any diagnoses given to your child:
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I. General Information
Describe what new concerns, if any, you have about your child:
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What areas do you feel have improved since the child's last assessment?
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What areas do you feel have NOT improved since the child's last assessment?
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II. Health History
Has any health history changed since the child's last evaluation (last 6-12 months)? Please include surgeries, vision or hearing changes, hospitalizations:
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Does your child have a specialized diet? Does your child have any food allergies? Does your child eat a variety of foods and are they able to take in adequate nutrition?
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What medication is your child currently on? Please include dosage and purpose of the medication.
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III. Current Treatment
Does your child receive any other therapies besides at GASLC? If yes, where? Please provide therapists' names, etc.
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Please describe any assistive equipment your child uses. Is the equipment well fitting and in good working order or does it need to be updated? :
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What new goals/skills would you like your child to address in OT, PT, and/or Speech?
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IV. Behavior/Play
Describe any behavior problems you have with your child:
What methods do you use during these behaviors?
What are your child’s interests, favorite play activities, toys, games etc.?
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What are your child's strengths?
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V. Current Educational Status
Name of school presently attending:
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Grade or level:
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Does your child have an IEP:
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Yes
No
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Describe general progress and behavior in school:
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Is the child in a special education classroom or receiving tutoring for any reason? If so, specify where and for what reason:
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VI. Additional Parent Comments
Please provide any additional information you would like us to know:
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Completed by:
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Relationship to Client:
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Email
*
example@example.com
Date
*
-
Month
-
Day
Year
Submit
Should be Empty: