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My name is:___________________________ My teacher is: _____________________ I am _______years old I am a Boy:__________ Girl: __________ My Primary language is:__________ _________ Secondary Language?_________________ I have _______________brothers and ________________sisters. Family situation (one/two parents, other adults, divorce, separation, etc.) _________________________________________________________________________ Any other household members living with me? Please specify: ______________________________________________________________ 2. My previous school experience is: (where and when)____________________________________________________________ I separate from my parent(s)/guardian(s): smoothly _______ with some anxiety _____ with difficulty ______ I am unable to separate ____________ Comments: _________________________________________________________________ 3. I should usually arrive at school with my (Please place am or pm on line as applicable): ____________Parent/Guardian ____________Babysitter _____________Carpool _____________ Bus (Route #_________) 4. My general physical health is: Good ________ Average ________ Poor ____________ Allergies: ___________________________________________________ Special Conditions: ____________________________________________ 5. Self Care: I can dress: Alone _______ With Assistance ______ I can use the toilet: By myself _______ I need help __________ I can eat: By myself _______ I need help ___________ I can brush my teeth: By myself________ I need help _____________ I take a daytime nap and can settle myself______________ I don’t nap____________ 6. My Interests are: Indoors:________________________________________________________________ Outdoors: ______________________________________________________________ Social-Emotional Development: Ї I initiate activities _________ I play alone________ I like to be invited_________ Ї I play mostly with children: of the same age _______ younger______ older_______ Ї I move into new environments: easily________ hesitantly______ not at all________ In group activities I get: actively involved_________moderately involved_________ I don’t like to get involved at all__________________ Any developmental concerns? (Speech, Coordination, Comprehension, Following directions) ___________________________________________________________________________ ___________________________________________________________________________ 8. A Little Bit About Me If you came to my house for dinner, we would probably have: ___________________________________________________________________________ My Favorite food is:__________________________________________________________ This is what I do before I go to bed:______________________________________________ ___________________________________________________________________________ My bedtime is usually:_________________________________________________________ I brush my teeth ___________times a day My ethnic background is:______________________________________________________ My family traditions include:___________________________________________________ ___________________________________________________________________________ The holidays I celebrate with my family are:___________________________________ ___________________________________________________________________________ My religious background is:_____________________________________________________ It is important to me_____________________It is not important to me___________________ During family time and/or on weekends, we like to:__________________________________ ____________________________________________________________________________ When I misbehave, my consequences are:___________________________________________ When I am scared or upset, I am comforted by:_______________________________________ Anything else we should know about you?___________________________________________ _____________________________________________________________________________ BDXfhjХЦ!#ю№Яб0Iф ysmkkkkkkk(  X Z \ ­ Џ 8 Ÿ в{y{{y 'DXfhЛНnp­ЏFqqka[    рР!FsУХы9;hЋв!šьюDGˆŠЭЯсZ’’з*.02IL–˜тф Z ­   X  ’ xggg88˜ўh’ ы 8 : ‡ Ђ Є т /  д ! r œ Ÿ я AŽп,.€ик00~€ге+-ав  в$%F’’ 0в&'()*Times New Roman Wingdings Tahoma ImpactTimes New Roman CETimes New Roman CyrTimes New Roman GreekTimes New Roman TurTimes New Roman (Hebrew) Times New Roman (Arabic) Times New Roman Baltic Times New Roman (Vietnamese) Tahoma CE Tahoma Cyr Tahoma Greek Tahoma Tur Tahoma (Hebrew) Tahoma (Arabic) Tahoma Baltic Tahoma (Vietnamese) Tahoma (Thai) Impact CE Impact Cyr Impact Greek Impact Tur Impact Balticџџџџџџџџ