The Odyssey School Free Screening Information Form

All participants in the Free Screening Event must submit this form in advance of the scheduled screening date.

Child Namerequired

First and Last Name

Birth Daterequired (mm/dd/yyyy)

Only children ages 8 and under are eligible for the free screening.

Current Schoolrequired

Grade Levelrequired

Only children ages 8 and under are eligible for the free screening.

How did you hear about The Odyssey School's free screening?required

Name of First Parentrequired

Name of Second Parent

Home Address

Address 1required
Address 2
Address 3
Cityrequired
Staterequired
Region
Zip Coderequired (ex. 06108 or 06108-0809)
Country

Primary Phone

Phonerequired
Ext

Primary Emailrequired

Secondary Phone

Phone
Ext

Secondary Email

Main Concernsrequired

What are your concerns about your child?

Family Historyrequired

Does someone in your family have a history of reading, writing or speaking difficulties? If yes, please explain.

Hearing Difficulty?required

Does your child have any hearing difficulties? If yes, please explain.

Ear Infections?required

Does your child have a history of repeated ear infections? If yes, please explain.

School Performancerequired

Has your child been experiencing specific difficulties in school? If so, what kinds?

Sustained Attentionrequired

Do you believe that your child has difficulties with sustaining attention to tasks? Please explain.

Delays in Learning to Walk?*

Has your child demonstrated delays in learning to walk?

yes no

Delays in Learning to Talk?*

Has your child demonstrated delays in learning to talk?

yes no

Delays in Play Behaviors?*

Has your child demonstrated delays in play behaviors?

yes no

Delayed Development?required

Do you believe your child’s development is delayed? If so, in what ways?

Psycho Educational Evaluation*

Has your child had a Psycho Educational Evaluation?

Yes No

If yes, when?

Type date of last Psycho Educational Evaluation.

Speech and Language Assessment*

Has your child had a Speech and Language Assessment?

Yes No

Individualized Education Program (IEP) *

Does your child have a current IEP?

Yes No

Other Evalulations*

Has your child had any other evaluations?

Yes No

If Yes, what other Evaluations AND when?

Name any other evaluations AND the date that they occurred.

Struggle with Specific Skills

Simply select Yes to indicate that your child is struggling with the skill and No if your child has never struggled with learning the skill.

Learning common nursery rhymes*

yes no n/a

Learning and remembering the names of letters, colors, days of the week, months of the year*

yes no n/a

Learning how to pronounce multi-syllabic words such as animal, cinnamon, spaghetti*

yes no n/a

Learning to recognize or generate rhyming words*

yes no n/a

Learning to express himself/herself*

yes no n/a

Acquiring basic reading skills (if age appropriate)*

yes no n/a

Confusing words that sound alike, such as tornado for volcano, head lights for head lice*

yes no n/a

Needing extra time to respond to questions*

yes no n/a

Learning to associate letters with sounds*

yes no n/a

Learning strategies for reading new and unfamiliar words*

yes no n/a

Complaining about how hard school is*

yes no n/a

Making wild guesses when trying to read a word*

yes no n/a

Reading requires great effort and takes place at a slow pace*

yes no n/a

Often anxious when speaking, reading or being called on in class*

yes no n/a

Learning rules for spelling*

yes no n/a

Interested in School Enrollment*

Yes No