JI Testing Application JI Testing Services Application Step 1 of 4 - General Information 0% General InformationStudent / Adult* This application is for my DEPENDENT (student testing) This application is for MYSELF (I am an adult) Applicant's Name:*Person to be tested: First Last Date of Birth:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Current Age:*Please enter a number from 1 to 100.Current Grade:If Applicant is currently in school, indicate grade level:Please enter a number from 1 to 12.Male/Female:*MaleFemaleContact InformationPrimary Contact Parent / Guardian Name:* First Last Applicant Type Check here if you are an ADULT and this is YOURSELF. Primary Phone Number:*Primary Email Address:* Relationship To Applicant:If an ADULT application, indicate 'self'.Secondary Contact Parent / Guardian Name:If you are an ADULT Applicant, this is optional. First Last Secondary ContactDoes Secondary Contact also wish to receive communication from Joshua Institute? Yes No Secondary Phone Number:Secondary Email Address: Relationship To Applicant:Applicant's Primary Address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Testing Purpose*I am only interested in Testing Services at this time.I am interested in Educational Therapy Services. I understand I must also complete and submit an Ed Services Application in addition to this Testing application.I am interested in the Academy. I understand I must also complete and submit an Academy Application in addition to this Testing application.Testing NeededCognitiveAcademic Achievement & Oral LanguageSEARCHIf unsure, check here: I am unsure which tests are needed. Reason for Testing*Explain why you are seeking to have testing done (brief overview):Previous Testing ResultsPlease upload the Applicant's previous test results, if any (e.g. PsychEd Evaluation or IEP Eligibility Report) Accepted file types: pdf, png, jpg, docx. Family HistoryApplicant is / was: Raised with biological parent/s Adopted In foster care Applicant lives with (check all that apply): Birth Mother Birth Father Stepmother Stepfather Legal Guardian Spouse Life Partner Friends / Roommates Other Siblings*Please list all sibling names and ages (if none, mark n/a):Describe Applicant's relationship with other members of the family:Is there a history of learning difficulties in Applicant's family?*YesNoIf yes, please explain:*Has Applicant experienced any childhood trauma?*YesNoIf yes, please explain:*Stressful Family Events* Death in the family Separation / Divorce Remarriage Other (If any are selected, please explain how the event affected the applicant).* Medical & Developmental HistoryBirthApplicant was:Full TermPrematureList any complications Applicant had in-utero:List any complications Applicant had at birth:Include the number of weeks if Applicant was born prematurely.Infant / Childhood IssuesCheck all that apply to Applicant. Colic Eating Sleeping Crawling Walking / Running Bedwetting General slow development None Surgeries:List dates and types of any surgeries Applicant has undergone:Childhood IssuesCheck all that apply to Applicant and explain below: Needs glasses Wears glasses Frequent ear infections Hearing difficulties Needs hearing aids Wears hearing aids Allergies/Asthma Runs high fevers Experienced a head injury Has or had seizure / convulsion / staring spell / Epilepsy Further details:Include type of glasses (reading or distance), date and explanation of head injury, type(s) of seizure, etc.:Medical DiagnosesApplicant has been diagnosed with: ADD ADHD Learning Disability ASD ODD OCD Other If "Other" please state here:Recent Medical Exams: Physical Vision Hearing Speech Other Date of Physical Exam: Date Format: MM slash DD slash YYYY Results of Physical Exam:"Normal" or list any relevant issues.Date of Visual Exam: Date Format: MM slash DD slash YYYY Results of Visual Exam:*Indicate "Normal" results or list any relevant issues.Date of Hearing Exam: Date Format: MM slash DD slash YYYY Results of Visual Exam:*Indicate "Normal" results or list any relevant issues.Date of Speech Exam: Date Format: MM slash DD slash YYYY Results of Speech Exam:*Indicate "Normal" results or list any relevant issues.Date of "Other" Exam Date Format: MM slash DD slash YYYY Results of "Other" Exam:*Please specify type of Exam and Indicate "Normal" results or list any relevant issues. Social & Behavioral HistoryCheck all that apply to Applicant:* Enjoys/enjoyed school Complains/complained about school Dependent Independent Lacks common sense Stubborn Shy Passive Confident Aggressive Anxious Overly sensitive Overly fearful Moody Easily distracted Easily frustrated Self-centered Prefers playing with much older children Prefers playing with much younger children Is there any other information you would like to share with Joshua Institute?Submit ApplicationAgreement to Submit Testing Application*I have filled out the Testing Application to the best of my knowledge. I give Joshua Institute permission to test my dependent student / myself (Applicant" listed above). I agree to pay applicable fees (cash or check) on the day of testing. Checking this box represents my signature and consent.Date* Date Format: MM slash DD slash YYYY
