The Weaver Center

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  • Services
    • Initial Consultation
    • Evaluation
    • School and Professional Advocacy
    • Self Advocacy Method (SAM)
    • Therapy Services
    • Small Group Tutoring
    • Educational/Organizational Tutoring and Coaching Services
    • Vocational Evaluations
    • Follow-Up Services
    • IEP Info For Parents
  • Resources
    • Vested Academics
    • Articles >
      • Attention Deficit: A Curse And Delight
      • An Autobiography of a Dyslexic Youth
      • Prisoners of Time
      • Recommended Reading
    • Multimedia >
      • Blog
      • Videos
      • Podcasts
    • Glossary of Terms
    • Our Forms >
      • Authorization to Release Information
      • Child questionnaire
      • Patient information form
      • Adult questionnaire
      • Vanderbilt initial assessment - Parent
      • Vanderbilt Follow-up assessment - Parent
      • Vanderbilt initial assessment - Teacher
      • Vanderbilt Follow-up assessment - Teacher
  • The Team
    • Denise Bernardi , M.Ed.
    • Michael G. Hehir , Psy.D.
    • Michael Preston , Ph.D.
    • Marla Stone , M.A.,CMC.
    • Robert (Buck) A. Weaver , III, Ph.D.
    • Linnea Weaver , M.S., CCC-SLP
    • Beverly Weinberg,  M. ED.
  • Contact
  • Home
  • Services
    • Initial Consultation
    • Evaluation
    • School and Professional Advocacy
    • Self Advocacy Method (SAM)
    • Therapy Services
    • Small Group Tutoring
    • Educational/Organizational Tutoring and Coaching Services
    • Vocational Evaluations
    • Follow-Up Services
    • IEP Info For Parents
  • Resources
    • Vested Academics
    • Articles >
      • Attention Deficit: A Curse And Delight
      • An Autobiography of a Dyslexic Youth
      • Prisoners of Time
      • Recommended Reading
    • Multimedia >
      • Blog
      • Videos
      • Podcasts
    • Glossary of Terms
    • Our Forms >
      • Authorization to Release Information
      • Child questionnaire
      • Patient information form
      • Adult questionnaire
      • Vanderbilt initial assessment - Parent
      • Vanderbilt Follow-up assessment - Parent
      • Vanderbilt initial assessment - Teacher
      • Vanderbilt Follow-up assessment - Teacher
  • The Team
    • Denise Bernardi , M.Ed.
    • Michael G. Hehir , Psy.D.
    • Michael Preston , Ph.D.
    • Marla Stone , M.A.,CMC.
    • Robert (Buck) A. Weaver , III, Ph.D.
    • Linnea Weaver , M.S., CCC-SLP
    • Beverly Weinberg,  M. ED.
  • Contact

    Child questionnaire








    Family history


    Child being tested:

    Brothers and/or sisters:





    Please list relatives who have (or had) school problems: (*Family members include: biological parents, siblings, grandparents, aunts, uncles. Please include whether maternal or paternal)
    Relatives*
    Name: Maternal side
    School/Learning Difficulties
    (language, reading, writing, spelling, mathematics, foreign languages, etc.)
    Relatives*
    Name: Paternal side
    School/Learning Difficulties
    (language, reading, writing, spelling, mathematics, foreign languages, etc.)

    Please list biological relatives with behavior problems
    Relatives*
    Name: Paternal side
    Social/Emotional or Behavioral Difficulties
    (overactive, restless, withdrawn, trouble with the law, depression, bipolar/alcohol/substance abuse)
    Relatives*
    Name: Paternal side
    Social/Emotional or Behavioral Difficulties
    (overactive, restless, withdrawn, trouble with the law, depression, bipolar/alcohol/substance abuse)




    Medical History (of child being test)
















    Developmental History

    Compared to other children, did child have problems learning:




    Testing History
    Please rank your child's self-esteem (self-confidence) in the following areas (1=low; 5=high):



    School History









    Child's present school and full address:


    Are there any other professionals, outside of school, working with your child (e.g. TUtors, coaches, therapist, etc.)?

    Max file size: 20MB
    Please upload a scan of your signature
Submit
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Hours

By appointment  

Telephone

(508) 358-1112

Email

​info@weavercenter.org