Special Education Assessment Form

Age range

Strengths of the Child

Background Information

Type of Birth

Birth Cry

Birth Weight

Planned or Unplanned

Presence of Birth Complications

Specify Birth Complications

Milestones

Motor

Cognitive

Speech

Social and Emotional

Family History

Type of Family

Family Tree

Presence of Mental Disorder in the Family

Specify Mental Disorder Details

Educational History

Syllabus

School change

Remarks

Class failures

Remarks option for covid era details related to learning

Has phonic awareness

Learning by sight

Tuition attending

Type of Tuition

Option to add any other details

Presenting Complaints

History of Presenting Complaints

Detailed History

Behavioral Observation

Rapport Establishment

Subject appeared to be

Attitude was

Eye Contact

Alertness and Consciousness

Facial expressions were

Attention

Psychomotor Activity

Speech

Cooperation

Motivation

Comprehension

Problems Related to Vision/Hearing/Motor/Other

Stereotypical repetitive behaviors

Responds to simple questions

Respond to instructions

Academic Observation

List academic observation

Test Administered

Brigance Set of Basic Skills

Grade Level Assessment Device (GLAD)

Schonell Reading Test

Schonell Spelling Test A & B

Test Findings

On Brigance Set of Basic Skills

Brigance Assessment of Basic Skills

Administered to assess the child's scholastic abilities

SL No	Domains	Child's Performance
1	Color recognition
2	Visual Discrimination
3	Visuo motor skills
4	Visual memory
5	Body Image
6	Gross motor coordination
7	Identification of body parts
8	Directional and positional skills
9	Fine motor skills
10	Verbal fluency
11	Verbal directions
12	Articulation of sounds
13	Personal data response
14	Sentence memory
15	Counting
16	Alphabets
17	Numerical recognition
18	Numerical comprehension
19	Recognition of lower case letters
20	Recognition of upper case letters
21	Writing names
22	Numbers in sequence
23	Lower case letters by dictation
24	Upper case letters by dictation

Grade Level Assessment Device (GLAD)

Administered for the purpose of educational assessment to assess the cause of learning difficulty

Areas affected (list out):

Domains	Grade level	Child's Performance
Concepts
Reading
Writing
Spelling
Mathematics
Comprehension
Malayalam
Hindi

Schonell Reading and Spelling Test A & B

Administered to understand the reading and spelling level

READING

Number of words read correctly
Reading Age

SPELLING

Number of words spelled correctly
Spelling age

Summary and Impression

Summary of the child's current condition:

Diagnostic impression:

Therapy Recommendations

Detailed recommendations:

Select recommended therapies:

Clinical Psychology

Occupational therapy

Speech therapy

ABA

Special education

Developmental pediatrician

Developmental neurologist

Psychiatrist

Follow ups