Initial Inquiry Form for Children

Instructions

Please provide us with the following information so that we can determine how to best proceed in scheduling appointments and evaluating your child. All information provided will remain confidential. All sections must be completed. Write “N/A” in any blank that is not applicable.

Parent One Name

First Name

Last Name

Parent One Phone

(###)

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Parent One Email

Parent One Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent Two Name

First Name

Last Name

Parent Two Phone

(###)

###

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Parent Two Email

Parent Two Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Please explain custody arrangements if parents are living separately.

Child's Current Grade

Name of Educational Lawyer (if applicable)

Name of Educational Advocate (if applicable)

Services you are seeking (Please select ONE)

comprehensive neuropsychological evaluation

ADHD and Executive Functioning Clinic

Learning Disability and Dyslexia Clinic

Autism Screening Clinic

Transition Planning Consultation

Tell us about your concerns.

Please provide a brief description of the concerns you have about your child’s learning, emotional functioning and/or behavior. Include any relevant medical or learning diagnoses and the educational, therapeutic and/or medical services your child is currently receiving.

How did you learn about Dr. Schmidt’s services?