Telephone: (802) 878 - 5313
Located at: 6 Hillcrest Road
Essex Junction, VT 05452

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Providing children and their families with quality diagnostic & educational services.

Online Forms

All Questionnaire

Parent Questionnaire

 
 
 
 
 


 


 


 


 
 

 

Birth/Developmental History

Pregnacy


 
 
 

lbs.
ozs.
 

Developmental Milestones

 

 

 

 

 
 

Medical History

 
 

 

 

 

 

 

 

 

 
 

 
 

Family Medical History


 
 

Social and Behavioral History

 
 

 

 

 

 

Provider Reason Dates
Provider Reason Dates
Provider Reason Dates
 

Educational History


 

 


School Address
 


Special educator(s)?
 

Grade(s) Name of School
Years Attended
Grade(s) Name of School
Years Attended
Grade(s) Name of School
Years Attended
 
 

 
 
 

 

Evaluator Place of Evaluation Date
Conclusions
Evaluator Place of Evaluation Date
Conclusions
Evaluator Place of Evaluation Date
Conclusions
 
 

Please mail any previous reports to 6 Hillcrest Road, Essex Junction, VT 05452 to maximize the benefits of this evaluation and to assure that the same tests are not given twice, possibly invalidating results.

Thank you for completing this form. We look forward to meeting with your and your child.


 

 

 
 
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