Student Testing Application - Joshua Institute

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- Adult Testing Application
- Student Testing Application

Student Application for Testing and/or Educational Services

Step 1 of 6 - General Information

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General Information
Student Name:*
First Middle Initial Last
Nickname/Name Preferred:
Date of Birth:*
Age:*
Please enter a number from 1 to 100.
Male/Female:*
- Male
- Female
Home Address:*
Street Address Address Line 2 City State ZIP Code
Primary Contact Name:*
First Last
Relationship To Student:
Occupation:
Primary Phone Number:*
Primary Email Address:*
Secondary Contact's Name:*
First Last
Occupation:
Phone Number:*
Secondary Email Address:*
Emergency Contact:*
First Last
Relationship:*
Emergency Contact's Phone Number:*
Referred by:
First Last
Name of school your child currently attends:*
Grade:*
Please enter a number from 1 to 12.
Teacher's Name:

Permission Testing
PLEASE NOTE: For us to best understand where your child is academically and cognitively, Academic Testing should not be more than 1 year old, and Cognitive Testing should not be more than 3 years old. If you are unsure of which tests are needed, if any, please mark the appropriate box, and our Director of Testing & Educational Services will meet with you.
Which test(s) does your student need?*
The cost for the Cognitive Ability and Academic Achievement tests combined is usually $875.00.
- Cognitive Ability - $500.00
- Academic Achievement - $375.00
- Executive Function Assessment - $125
- Search + Teach (Pre-1st grade / <7 years old) - $100.00
- I do not know which testing may be needed.
- NO further testing is needed at this time, and I will submit current testing results.
Consent:*
I give permission to Joshua Institute to test my son/daughter.
Full payment (cash or check) is due at time of testing.*
Please mail or drop off payment at:

Attn: Britt Collingwood
Joshua Institute
2150 W. Cherry Lane
Meridian, ID 83642

If you have any questions, please call (208)-893-5130 or email bcollingwood@joshuainstitute.org.
I agree to pay the amount above in full at time of testing.
Current Testing Results
Please upload your student's current test results, if any:
Accepted file types: pdf, png, jpg, docx.

Family History
Child is living with (check all that apply):*
- Birth Father
- Birth Mother
- Stepfather
- Stepmother
- Legal Guardian
- Other
Check if applicable:
- Child is adopted
- Child is fostered
Since the child's birth there has been:*
Check all that apply.
- Death in the family
- Separation
- Divorce
- Remarriage of Mother
- Remarriage of Father
- Other major life events or trauma
- None
Please explain the reaction of the child:*
Are there other children in the family?*
- Yes
- No
Please list any other children in the family, their age, and the school they currently attend.*
Is there a history of learning difficulties in your family?*
- Yes
- No
If yes, please explain:*
Briefly describe your child's relationship with you, your spouse, and other members of the family:*

Medical/Developmental History
Child was:*
- Full Term
- Premature
State any complications which occurred during pregnancy (e.g. toxemia, diabetes, etc.):*
State any complications your child had immediately after birth (e.g. difficulty breathing, blue color, etc.):*
My student has had the following within the last year (please check all that apply):*
- Physical exam
- Eye exam
- Hearing exam
- Speech evaluation
- None
Please list the approximate dates and results of the test(s).*
Please check the following if your student had problems in infancy or childhood with:
- Colic
- Sleeping
- Talking
- Bedwetting
- Crawling
- Eating
- Walking/running
- General slow development
- None
Child (check where applicable):
- Needs glasses
- Wears glasses
- Has allergies
- Has asthma
- Has/had seizures, convulsions, or staring spells
- Has/had high fevers
- Has/had frequent ear infections
- Has/had hearing difficulties
- Experienced injury/accident to head
- None
Please explain:*

Educational History
Child is currently in:*
- Elementary
- Junior high / Middle school
- High school
Please list ALL schools previously attended (preschool to present), the grade(s) your student was in, and the reason for changing schools.*
Child writes with:*
- Right hand
- Left hand
- Uses both hands
- Mirror writer
Has the child repeated any grade(s)?*
- Yes
- No
Please list the grade(s):*
Has the child ever received tutoring?*
- Yes
- No
Please list the subjects:*
Has the child ever been enrolled in special classes?*
- Yes
- No
Please list the class type(s):*
Has the child received physical/occupational therapy?*
- Yes
- No
Has the child received speech or language therapy?*
- Yes
- No
What is your child's BEST subject?*
What is your child's WORST subject?*
Child has been tested before (other than Cognitive and Academic testing):*
- Yes
- No
If yes, please give type of test, date and location of testing:*
Has the child ever had a/an:*
- IEP
- 504 Plan
- Other accomodations
- None
Please upload these documents:
Drop files here or

Accepted file types: pdf, png, jpg, docx.
Please explain the accommodation:*
Has the child ever been diagnosed with:*
- ADD
- ADHD
- Learning Disabled
- Other
- None
Please explain:*
Additional comments or information regarding school history:
State the area(s) in which you feel your child needs help:*

Social / Behavioral History
Check all descriptions that apply to your child's social/behavioral history:*
- Independent
- Anxious
- Dishonest
- Shy
- Passive
- Lacks common sense
- Easily distracted
- Overly fearful
- Enjoys school
- Makes friends easily
- Stubborn
- Aggressive
- Withdrawn
- Moody
- Confident
- Dependent
- Complains about school
- Overly sensitive
- Self-centered
- Easily frustrated
- Prefers playing with much older children
- Prefers playing with much younger children
Please list any additional information you would like to share before testing:
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Adult Testing Application

Adult Testing Application for Learning Disabilities

Step 1 of 9 - General Information

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General Information
Name:*
First Last
Nickname/Preferred Name:
Date of Birth:*
Age:*
Please enter a number from 1 to 100.
Male/Female:*
- Male
- Female
Address:*
Street Address Address Line 2 City State ZIP Code
Phone Number:*
Email:*
Referred by: (Facebook, Radio, Staff, Friend, etc.)*

Family History
You grew up in a home with (check all that apply):*
- Birth Father
- Birth Mother
- Step-Father
- Step-Mother
- Adopted
- Legal Guardian
- Foster
- Other
Please explain:*
Did you experience any of the following as a child/adolescent:*
Check all that apply.
- Death in the family
- Separation
- Divorce
- Remarriage of Mother
- Remarriage of Father
- Other major trauma
- None
Please explain:*
Is there a history of learning difficulties in your family?*
- Yes
- No
Please explain:*
Briefly describe your relationship with your family members:*

Medical/Developmental History
Birth History - Were you:*
- Full Term
- Premature
State any known pre-natal complications your mother may have had during her pregnancy with you (e.g., toxemia, diabetes, etc.):
State any complications immediately after birth (e.g., difficulty breathing, blue color, etc.):
Select all that apply:*
- Recent physical exam
- Recent eye exam
- Recent hearing exam
- Recent speech evaluation
- None
Please state the approximate date(s) of the exam(s) and the result(s):*
Check any problems in infancy or childhood with:
- Colic
- Sleeping
- Talking
- Bedwetting
- Crawling
- Eating
- Walking/running
- General slow development
- None
Childhood medical/development issues:
Check all that apply.
- Needs glasses
- Wears glasses
- Allergies/asthma
- Seizures, convulsions, or staring spells
- High Fevers
- Frequent ear infections
- Hearing difficulties
- Experienced injury/accident to head
- None
Please explain:*

School History
Name of Elementary School:*
Location:*
City State
Grades Attended:*
Do you have additional Elementary Schools to add?*
- Yes
- No
Reason for changing/leaving the aforementioned school:*
Elementary School #2
Name of Elementary School:*
Location:*
City State
Grades Attended:*
Do you have additional Elementary Schools to add?*
- Yes
- No
Reason for changing/leaving the aforementioned school:*
Elementary School #3
Name of Elementary School:*
Location:*
City State
Grades Attended:*
Do you have additional Elementary Schools to add?*
- Yes
- No
Reason for changing/leaving the aforementioned school:*
Elementary School #4
Name of Elementary School:*
Location*
City State
Grades Attended:*
Do you have additional Elementary Schools to add?*
- Yes
- No
Reason for changing/leaving the aforementioned school:*
Elementary School #5
Name of Elementary School:*
Location:*
City State
Grades Attended:*

Junior High/Middle School
Name of Junior High/Middle School:*
Location*
City State
Grades Attended:*
Do you have additional Junior High/Middle Schools to add?*
- Yes
- No
Reason for changing/leaving the aforementioned school:*
Junior High/Middle School #2
Name of Junior High/Middle School:*
Location*
City State
Grades Attended:*
Do you have additional Junior High/Middle Schools to add?*
- Yes
- No
Reason for changing/leaving the aforementioned school:*
Junior High/Middle School #3
Name of Junior High/Middle School:*
Location*
City State
Grades Attended:*
Do you have additional Junior High/Middle Schools to add?*
- Yes
- No
Reason for changing/leaving the aforementioned school:*
Junior High/Middle School #4
Name of Junior High/Middle School:*
Location*
City State
Grades Attended:*
Do you have additional Junior High/Middle Schools to add?*
- Yes
- No
Reason for changing/leaving the aforementioned school:*
Junior High/Middle School #5
Name of Junior High/Middle School:*
Location*
City State
Grades Attended:*

High School
Name of High School:*
Location*
City State
Do you have additional High Schools to add?*
- Yes
- No
Reason for changing/leaving the aforementioned school:*
High School #2
Name of High School:*
Location*
City State
Grades Attended:*
Do you have additional High Schools to add?*
- Yes
- No
Reason for changing/leaving the aforementioned school:*
High School #3
Name of High School:*
Location*
City State
Grades Attended:*
Do you have additional High Schools to add?*
- Yes
- No
Reason for changing/leaving the aforementioned school:*
High School #4
Name of High School:*
Location*
City State
Grades Attended:*
Do you have additional High Schools to add?*
- Yes
- No
Reason for changing/leaving the aforementioned school:*
High School #5
Name of High School:*
Location*
City State
Grades Attended:*

Additional Educational Information
Handedness:*
- Right Hand
- Left Hand
- Uses both hands
- Mirror Writer
Have you repeated any grade(s)?*
- Yes
- No
Please list the grade(s):*
Have you ever received tutoring?*
- Yes
- No
Please list the subjects:*
Have you ever been enrolled in special classes?*
- Yes
- No
Please list the class type(s):*
Have you received physical/occupational therapy?*
- Yes
- No
Have you received speech or language therapy?*
- Yes
- No

What was your BEST subject while attending school?*
What was your WORST subject while attending school?*
Have you ever been tested before?*
- Yes
- No
Date*
Please give the approximate day of the testing.
Location of the testing:*
City State
Have you ever had a:*
- IEP
- 504 Plan
- Other accomodation
Please explain the accommodation:*
Have you been diagnosed with:*
- ADD
- ADHD
- Learning Disabled
- Other
- None
Please explain:*
Additional comments or information regarding school history:
State the area(s) in which you feel you need help:*

Social/Behavioral History
Check where applicable:
- Independent
- Anxious
- Dishonest
- Shy
- Passive
- Lacks common sense
- Easily distracted
- Overly fearful
- Enjoys learning
- Makes friends easily
- Stubborn
- Aggressive
- Withdrawn
- Moody
- Confident
- Dependent
- Complains
- Overly sensitive
- Self-centered
- Easily frustrated
Please list any additional information you would like to share before testing:
I hereby give Joshua Institute consent to test me.*
- Yes

2150 W. Cherry Lane

Meridian, ID 83642

208-893-5130

Info@JoshuaInstitute.org

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About
Academy
Educational Therapy
Testing Services
- Adult Testing Application
- Student Testing Application