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Assessment Form

Child's Information:

First Name

MiddleName

Last Name

Age

Present Grade (If Applicable)

Birthday

Gender

Parent's Information:

First Name

Last Name

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Country

Cell Phone Number

Work Phone Number

Health:

List any allergies your child may have:

List all foods your child is not allowed to have:

List any medical diagnosis your child may have:

If your child is taking any therapies please list them below:

Please explain any other important health information we should be aware of. For example: seizures, panic attacks, etc.

Educational History

How is the student currently enrolled?

Public School

Charter School

Private School

Homeschool

School student is currently enrolled at:

Has the student ever been evaluated for educational, learning, behavioral, or emotional reasons?

Has your child ever repeated a grade level? If so, what grade?

Tangible Rewards

Select the tangible rewards your child likes from the following list:

iPad

Fuzzy toys

Toy cars

Stickers

Goldish

Doll

Slime

Candy

Play-doh

Chocolate

List any other rewards or things your child enjoys:

Please answer yes or no to the following questions:

Has your child ever used a token economy?

Does your child use any assistive communication device or tools?

Has your child ever used a picture schedule?

Has your child ever been part of a program specifically for kids with Autism?

How did you hear about Learning Cove Academy?

Friend

Online Search

Instagram

Facebook

Parent Organization

Therapist

Other

FEES
There is a non-refundable $50 assessment fee.

Sign below to state that you understand and agree with these terms.

Your Signature

Thanks for submitting!

Learning Cove Academy
3350 SW 144 Ave
Miami, Florida 33175
Phone: 786-321-5683 email: learningcoveacademy@gmail.com

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