"Referral for Re-evaluation (Preschool)"

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Referral for Re-Evaluation (Preschool)
PARENT/GUARDIAN COMPLETES THIS SECTION
Student’s Name: ______________________________
School: ________________________________
INFORMATION UPDATE:
Please describe any changes that may have taken place in your child’s life since the last evaluation (
dated ______)
that may be affecting his/her school performance
(e.g. divorce/separation of parents, serious or ongoing illness of family
member, death of family member, incarceration, counseling or therapy, medication , services through Madison Center, etc.):
__________________________________________________________________________________________
__________________________________________________________________________________________
Please list any serious illnesses, injuries, or surgeries your child has experienced. Also note the approximate
date (or child’s age at the time):________________________________________________________________
__________________________________________________________________________________________
Child’s Pediatrician:_________________________________________________________________________
Does your child presently have any medical problems (illnesses, etc.)? Yes
No _____
If yes, please describe _________________________________________________________________
Diagnosed when?_____________________________________________________________________
Does your child take any medication on a regular basis? Yes
No _____
If yes,
Medication Name:
Purpose:
Dosage
Start Date:
Side Effect:
_______________________
_______________________
_______________________
_______________________
Place ** next to medications listed above which are taken at school.
Has your child been formally tested/evaluated within the past three years? Yes ____ No_____
If yes, Date __________ Name of agency/evaluator _________________________________________
Does your child receive counseling? Yes ______ No ________ If yes, with whom: ______________________
Describe your child’s interests ________________________________________________________________
_________________________________________________________________________________________
What are the positive characteristics that describe your child socially/emotionally? _______________________
__________________________________________________________________________________________
From the parent/guardian perspective, describe your child's current difficulties (academic or behavioral)
__________________________________________________________________________________________
__________________________________________________________________________________________
Indicate any other information that the Multi-disciplinary team should know about your child ______________
__________________________________________________________________________________________
_____________________
_________________________________
DATE
Signature of Parent
Referral for Re-Evaluation (Preschool)
PARENT/GUARDIAN COMPLETES THIS SECTION
Student’s Name: ______________________________
School: ________________________________
INFORMATION UPDATE:
Please describe any changes that may have taken place in your child’s life since the last evaluation (
dated ______)
that may be affecting his/her school performance
(e.g. divorce/separation of parents, serious or ongoing illness of family
member, death of family member, incarceration, counseling or therapy, medication , services through Madison Center, etc.):
__________________________________________________________________________________________
__________________________________________________________________________________________
Please list any serious illnesses, injuries, or surgeries your child has experienced. Also note the approximate
date (or child’s age at the time):________________________________________________________________
__________________________________________________________________________________________
Child’s Pediatrician:_________________________________________________________________________
Does your child presently have any medical problems (illnesses, etc.)? Yes
No _____
If yes, please describe _________________________________________________________________
Diagnosed when?_____________________________________________________________________
Does your child take any medication on a regular basis? Yes
No _____
If yes,
Medication Name:
Purpose:
Dosage
Start Date:
Side Effect:
_______________________
_______________________
_______________________
_______________________
Place ** next to medications listed above which are taken at school.
Has your child been formally tested/evaluated within the past three years? Yes ____ No_____
If yes, Date __________ Name of agency/evaluator _________________________________________
Does your child receive counseling? Yes ______ No ________ If yes, with whom: ______________________
Describe your child’s interests ________________________________________________________________
_________________________________________________________________________________________
What are the positive characteristics that describe your child socially/emotionally? _______________________
__________________________________________________________________________________________
From the parent/guardian perspective, describe your child's current difficulties (academic or behavioral)
__________________________________________________________________________________________
__________________________________________________________________________________________
Indicate any other information that the Multi-disciplinary team should know about your child ______________
__________________________________________________________________________________________
_____________________
_________________________________
DATE
Signature of Parent
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