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Your E-mail Address		Repeat E-mail Address
General Information:
Student:		Date of Birth:
Age:		Birthplace:
Name of Parent/Guardian
Address:
		Referred by:
Ph#		Ph#
Student Ethnicity		Primary Lang.
Name of School Dist.		Ph#
Address
Name of School		Ph#
Level: Pre-School	Elementary	Middle/Jr.	High School
Present Grade level in school		Last grade completed
Medical Information
Does the child have a diagnosed brain injury/neurological disorder?			Yes No
Age when injury occurred
Type of Injury
Cause of Injury
Was the child unconscious?	YesNo	For how long?
Medical care:	In-patient hospital Out-patient hospital
Length of Hospital Stay
Extent of damage:	Mild	Moderate	Severe
What areas of the brain were affected?
Seizure Activity	YesNo	Age of onset?
Frequency	Duration	Last Incident
Describe, in detail, seizure activity
Medications or management of seizures
What was the child's estimated cognitive and educational status before the injury?
Services/Therapies received in the hospital:*
Social Work		Home/Hospital Instruction
Speech Therapy		Psychological Services
Occupational Therapy		Counseling
Physical Therapy		Neuropsychological Test
School Re-integration		Visit from home school