Please fill out your name
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First Name
Last Name
Best e-mail to contact your family
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Enter phone number if you would like to share
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Please fill out your learner's information
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First Name
Last Name
Their date of birth
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MM
DD
YYYY
Does your learner use spoken words to communicate?
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If yes, are they demonstrating a spoken vocabulary that is developmentally appropriate for their age?
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If your learner doesn't use spoken words to communicate, select N/A
Does your learner demonstrate the ability to understand spoken words at a developmentally appropriate level for their age?
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Does your learner have a medical diagnosis of any of the following: (Autism, ADHD, Down Syndrome, Medically Fragile, OCD, Other diagnosis that you feel impacts them on a daily basis)?
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If so, do they understand enough about their own needs to advocate for what they may need that is different from others in a given scenario or environment?
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If they are unaware or do not understand, select N/A
If your learner uses spoken words to communicate, can they identify their own emotions and share them with an adult?
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If your child doesn't use spoken words to communicate, select N/A
If your learner uses spoken words to communicate, are they able to look at their own behavior and determine what were safe and healthy choices and what is not, and discuss with an adult a plan to increase safer and healthier choices?
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If your child doesn't use spoken words to communicate, select N/A
If your learner does not use spoken words, how are they currently communicating at home, school, and in the community?
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Select N/A if your learner uses spoken words to communicate
When wanting a desired item, activity or person, check all that your learner currently can do:
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When an unexpected event happens in the natural environment (something good or bad, but interesting, different, socially significant), check all that your learner currently can do:
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When asked questions that relate to information that has no immediate visuals or signals in the environment (asking what happened in a book after it has been read and put away, asking about an event that has already passed, asking about general knowledge like what do you do when you are sick), check all that your learner currently can do:
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If your learner is a vocal communicator, what is their current mastery level of math?
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Select if applicable:
Above grade level
At grade level
Lagging at grade level
Below grade level
Well below (2+ grades) grade level
If your learner is a vocal communicator, what is their current mastery level of writing?
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Select if applicable:
Above grade level
At grade level
Lagging at grade level
Below grade level
Well below (2+ grades) grade level
If your learner is a vocal communicator, what is their current mastery level of reading?
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Select if applicable:
Above grade level
At grade level
Lagging behind grade level
Below grade level
Well below (2+ grades) below grade level
Select any of the behaviors your learner regularly exhibits:
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