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Your E-mail Address Repeat E-mail Address
General Information:
Student: Date of Birth:
Age: Birthplace:
Name of Parent/Guardian
    Referred by:
Ph# Ph#
Student Ethnicity Primary Lang.
Name of School Dist. Ph#
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