Student Testing Application - Joshua Institute

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2150 W. Cherry Lane

Meridian, ID 83642

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208-893-5130

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Student Testing Application

Student Testing Application for Learning Disabilities

Step 1 of 10 - General Information

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

Family History
Child is living with (check all that apply):*
- Birth Father
- Birth Mother
- Stepfather
- Stepmother
- Legal Guardian
- Other
Please explain:*
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 trauma
Please explain the reaction of the child:*
Are there other children in the family?*
- Yes
- No
Is there a history of learning difficulties in your family?*
- Yes
- No
Please explain:*
Briefly describe your child's relationship with you, your spouse, and other members of the family:*

Sibling #1:
Name:*
First Last
Age in years:*
Use zero if the child is less than a year old.
Please enter a number from 0 to 100.
Grade:
Use zero if the child is in preschool or kindergarten.
Please enter a number from 0 to 12.
Current school:
Are there additional children?*
- Yes
- No
Sibling #2:
Name:*
First Last
Age in years:*
Use zero if the child is less than a year old.
Please enter a number from 0 to 100.
Grade:
Use zero if the child is in preschool or kindergarten.
Please enter a number from 0 to 12.
Current school:
Are there additional children?*
- Yes
- No
Sibling #3:
Name:*
First Last
Age in years:*
Use zero if the child is less than a year old.
Please enter a number from 0 to 100.
Grade:
Use zero if the child is in preschool or kindergarten.
Please enter a number from 0 to 12.
Current school:
Are there additional children?*
- Yes
- No
Sibling #4:
Name:*
First Last
Age in years:*
Use zero if the child is less than a year old.
Please enter a number from 0 to 100.
Grade:
Use zero if the child is in preschool or kindergarten.
Please enter a number from 0 to 12.
Current school:
Are there additional children?*
- Yes
- No
Sibling #5:
Name:*
First Last
Age in years:*
Use zero if the child is less than a year old.
Please enter a number from 0 to 100.
Grade:
Use zero if the child is in preschool or kindergarten.
Please enter a number from 0 to 12.
Current school:
Are there additional children?*
- Yes
- No
Sibling #6:
Name:*
First Last
Age in years:*
Use zero if the child is less than a year old.
Please enter a number from 0 to 100.
Grade:
Use zero if the child is in preschool or kindergarten.
Please enter a number from 0 to 12.
Current school:
Are there additional children?*
- Yes
- No
Sibling #7:
Name:*
First Last
Age in years:*
Use zero if the child is less than a year old.
Please enter a number from 0 to 100.
Grade:
Use zero if the child is in preschool or kindergarten.
Please enter a number from 0 to 12.
Current school:
Are there additional children?*
- Yes
- No
Sibling #8:
Name:*
First Last
Age in years:*
Use zero if the child is less than a year old.
Please enter a number from 0 to 100.
Grade:
Use zero if the child is in preschool or kindergarten.
Please enter a number from 0 to 12.
Current school:
Are there additional children?*
- Yes
- No
Sibling #9:
Name:*
First Last
Age in years:*
Use zero if the child is less than a year old.
Please enter a number from 0 to 100.
Grade:
Use zero if the child is in preschool or kindergarten.
Please enter a number from 0 to 12.
Current school:
Are there additional children?*
- Yes
- No
Sibling #10:
Name:*
First Last
Age in years:*
Use zero if the child is less than a year old.
Please enter a number from 0 to 100.
Grade:
Use zero if the child is in preschool or kindergarten.
Please enter a number from 0 to 12.
Current school:

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.):
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
Child: (check where applicable)
- Needs glasses
- Wears glasses
- Has allergies/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:*

School History
Child is currently in:
- Elementary
- Junior high/Middle school
- High school
Elementary School
Name of elementary school:*
Location:*
City State
Grades attended:*
Reason for changing/leaving the aforementioned school:*
Do you have additional elementary schools to add?*
- Yes
- No
Elementary School #2
Name of elementary school:*
Location:*
City State
Grades attended:*
Reason for changing/leaving the aforementioned school:*
Do you have additional elementary schools to add?*
- Yes
- No
Elementary School #3
Name of elementary school:*
Location:*
City State
Grades attended:*
Reason for changing/leaving the aforementioned school:*
Do you have additional elementary schools to add?*
- Yes
- No
Elementary School #4
Name of elementary school:*
Location:*
City State
Grades attended:*
Reason for changing/leaving the aforementioned school:*
Do you have additional elementary schools to add?*
- Yes
- No
Elementary School #5
Name of elementary school:*
Location:*
City State
Grades attended:*
Reason for changing/leaving the aforementioned school:*

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

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

Additional Educational Information
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

State the child's BEST subject:*
State the child's WORST subject:*
Has the child been tested before?*
- Yes
- No
Date:*
Please give the approximate day of the testing.
Location of testing:*
City State
Has the child ever had a/an*
- IEP
- 504 Plan
- Other accomodation
- None
Please explain the accommodation:*
Has the child 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:
I hereby give Joshua Institute consent to test my child.*
- Yes

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