EXCEPTIONAL STUDENT EDUCATION Special Education Program
(Please fill out the form in its entirety so that we can better serve you and your student.)
Student Name *
Student Current Grade *
Is your child homeschooled? *
Name of your child's current school?
Interested in enrolling when? *
Parent/Guardian Name *
Phone Number *
Most recent testing date (Must be within the last 3 years or new testing will be required.) *
Does your child have a current IEP? (A copy will need to be provided with school application.) *
Current Level of support/setting:
What are your child's strengths?
At or above grade level in reading
At or above grade level in writing
At or above grade level in math
Communicates fluently with use of verbal language
Organized and has reasonable study skills
Minimal off-task or problematic behaviors
Works well independantly
What are your concerns/needs in Language Arts?
What are your concerns/needs in Math?
Basic Math Facts
Solving Word Problems
What are your concerns/needs in Communication?
Expressive Language Delays
Receptive Language Delays
Does your child have any medical needs or on medication?
Diagnosed Medical Condition
Diagnosed Mental Health Condition
What are your concerns/needs in Motor Skills?
Gross Motor Coordination
Fine Motor Coordination
Please describe sensory needs/aversion:
What are your child's areas of concern/needs in daily living skills?
Communicating Basic Wants/Needs
Understanding Social Cues
Does your child have any behavioral/social concerns?
Difficult to Redirect
Poor Social Boundaries
Elopes (Runs or walks away)
Engages in Self-stimulation (Stimming)
What are your child's areas of concern/needs in study/work skills?
Screams or Yells Frequently
Does Not Work Independently
Avoids Difficult Task
Remaining In Seat
Changes in schedule/routine
Please tell us any other concerns or needs your child has that would help us meet the academic needs *
Parent Priorities: *
Enter Your Email Address: *
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