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Student Assessment Information Form
= Required Fields
Your Details
Student Name
School
Date of Birth
Year Level
Current Learning Support
Place of child in family
Please select your child’s birth order within the family
One (first born)
Two (second born)
Three (third born)
Four (fourth born)
Five (fifth born)
Six (sixth born)
Presenting Problems
Please select from the following areas:
Reading
Spelling
Writing
Comprehension
Maths
Anxiety
Other
Comments on areas of learning difficulty
Milestones Reached
as expected
delayed
What areas?
Family history of learning difficulties
Strengths
Please choose the available reports you have
Guidance Officer
Speech Pathologist
Occupational Therapist
Educational Psychologist
Paediatrician
Other Specialist
Audiologist
Behavioural Optometrist
Please rate the level of concern
School's Concern
1 - Low
2
3
4
5 - High
Parent's Concern
1 - Low
2
3
4
5 - High
Does the student have an Individual Education Plan?
Yes
No
Any current medication?
What assistance would you like from SPELD Qld?
Parent / Guardian's Details
Title
Mr
Mrs
Ms
Miss
First Name
Last Name
Address
Suburb
State
Postcode
Email
Contact Telephone Number
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