Child Evaluation

:: Child Evaluation Form ::

IMPORTANT: This is an informal checklist to guide parents in their evaluation about their children’s problems so that the LSES consultants can provide appropriate advice to them. This should not be taken as a definitive diagnosis of the problem. If you are interested, please complete the form.

Notice: Field with * must be filled!

Your Child's Information :

Full Name:

Date of Birth: *

Order of Birth : *

Gender: *

Female Male

Race:

School:

Class/Level: *

Home Address: *

Questionnaire :

1.	Does your child display any hearing problems?	Yes No
2.	Does your child display any visual problems?	Yes No
3.	Does your child talk later than his/her peers?	Yes No
4.	Does your child walk later than his/her peers?	Yes No
5.	Does your child play/talk alone to him/herself?	Yes No
6.	Can your child recognize the English alphabet?	Yes No
7.	Can your child write his/her own name?	Yes No
8.	Can your child count/write numbers 1 to 100?	Yes No
9.	Can your child perform simple calculations?	Yes No
10.	Can your child follow any given instructions?	Yes No
11.	Is your child looked after by a maid while parents are at work?	Yes No
12.	Is your child misbehaving at home most of the time?	Yes No
13.	Is your child misbehaving in class most of the time?	Yes No
14.	Is your child failing in his/her studies all this while?	Yes No
15.	Is your child in the learning support program now?	Yes No
16.	Has your child been complained by his/her teachers?	Yes No
17.	Has your child been complained by his/her friends?	Yes No
18.	Has your child been complaining to you of feeling unwell lately?	Yes No
19.	Has your child been behaving differently from his/her normal self?	Yes No
20.	Has your child seen a psychologist/therapist/counselor?	Yes No

Scoring System

For Does-Questions 1-5, score 1 point for Yes and 0 point for No.
For Can-Questions 6-10, score 0 point for Yes and 1 point for No.
For Is-Questions 11-15, score 1 point for Yes and 0 point for No.
For Has-Questions 16-20, score 1 point for Yes and 0 point for No.

Total score is between 0 and 20:
If your total score is between 0 and 7, there is unlikely any problem with the child.
If your total score is between 8 and 12, there is a possibility of some problem with the child.
If your total score is between 13 and 20, there is a high possibility of problem with the child.

If there is problem with your child, please provide a brief description of your area of concern in the box:

If your child has seen a psychologist, provide the following data (optional):

Full-scale IQ: Verbal IQ: Performance IQ:

If you want further advice from us, please enter your email below and submit this form to us: