Initial Inquiry Questions for Children

Neuropsychology

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 out be completed. Write “N/A” in any blank that is not applicable.

Parent 1 Name

First Name

Last Name

Parent 1 Phone

(###)

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Parent 1 Email

Parent 1 Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent 2 Name

First Name

Last Name

Parent 2 Phone

(###)

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Parent 2 Email

Parent 2 Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Please explain custody arrangements if parents are living separately

Childs Name

First Name

Last Name

Childs Date of Birth

YYYY

Childs Current Grade

Childs School District

School District Special Education or private school contact (if applicable)

Current School Name

Current School Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Current School Phone

(###)

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Name of Educational Lawyer (if applicable)

Name of Educational Advocate (if applicable)

Service you are seeking (Select ONE)

comprehensive neuropsychological evaluation

ADHD and Executive Functioning Clinic

Learning Disability and Dyslexia Clinic

Autism Screening Clinic

Transition Planning Consultation

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?