Académique Documents
Professionnel Documents
Culture Documents
I. GENERAL INFORMATION
Name: ______________________________________________________
Learner’s Reference No. ______________________________________________________
Birthdate ______________________________________________________
Age ______________________________________________________
Address ______________________________________________________
Grade ______________________________________________________
Name of Father ______________________________________________________
Name of Mother ______________________________________________________
Name of Guardian ______________________________________________________
Primary Dialect ______________________________________________________
Date of Evaluation ______________________________________________________
Entry Date Program ______________________________________________________
Projected Termination Date ______________________________________________________
Date of Referral ______________________________________________________
Area: COMMUNICATION
A. RECEPTIVE
1. Understands the use of
I
You
Me
Mine
Yours
Is
Are
Today
Yesterday
Tomorrow
Was
Will
Under
On
Inside
Outside
1.10.Goodbye.
______________________________________________________________________
4. Able to say or write facts pertaining situation (e.g. Today is Monday. Brenna is
not here.)
_______________________________________________________________
2. Stands in line.
__________________________________________________________________________
3. Initiate greetings.
__________________________________________________________________________
b. Group time
_______________________________________________________________________
c. Waiting period
_______________________________________________________________________
e. Worksheet time
_______________________________________________________________________
7. Reads CVC’s.
__________________________________________________________________________
2. Writing skills
__________________________________________________________________________
7. Sets table.
__________________________________________________________________________
9. Washes dishes.
__________________________________________________________________________
Area: BEHAVIOR
1. General Compliance
__________________________________________________________________________
2. Adaptation
__________________________________________________________________________
3. Sensory interrogation
__________________________________________________________________________