Student Intake Information

Student Name

First

Last

Date of Birth

Grade

School

Allergies

Please list any allergies and also indicate if your child carries an auto injector. Thank you.

Medications / ADHD-ADD

If your child is currently taking medications to assist with ADHD/ADD, please let us know if they have taken this prior to coming in for their Intake Assessment with us. This includes anything that would be considered 'Natural' or prescribed by a Naturopath.

Parent 1

First

Last

Parent 1: Address

Parent 1: Phone Number

Please enter your mobile number.

Parent 1: Email Address

Please enter an email address that we are permitted to use for general contact, scheduling etc. Make sure it is an email address that will allow attachments. Thank you.

Parent 2

First

Last

Parent 2: Address

Please only fill this in if the address is different from above.

Parent 2: Phone Number

Please enter your mobile number.

Parent 2: Email Address

Please enter an email address that we are permitted to use for general contact, scheduling etc. Make sure it is an email address that will allow attachments. Thank you.

Learning History

Please provide some history of the difficulties your child is having. It does not need to be exhaustive, just some insight into when you first started to notice that they may be having a bit more difficulty than expected.

Current or Past Assistance

Please indicate if your child is currently receiving or has received in the past, any assistance in developing the skills that are currently an area of concern. Ex. resource, in class supports, accommodations or private assistance. When, how often and for how long etc.

Previous Testing / Assessment

Please indicate if your child has been assessed, i.e. Psycho-Educational Assessment, a screening, in-school assessments that lead to feedback or any other form of testing. If so, please indicate when and if any reports from this testing exist, please feel free to bring them with you to Novaread for the Intake Assessment

Strengths / Hobbies

Please let us know what your child enjoys, or maybe truly loves. This could be sports, music, baking, artistic endeavors, gaming or any number of other topics. Academics are important but they are not everything and given the children we work with typically find at least one area of school difficult, it is nice to have things to talk to them about away from school subjects.

Topics to Avoid

Please let us know if there is anything that we should not bring up. The visit for the Intake Assessment is roughly two hours and we want the experience to be a very positive one. For a basic example, your family may have recently lost a family pet. Let us know so we don't upset anyone by stumbling into a conversation about this.

Outcome

We are being given the opportunity to be part of your child's education, thank you. We want this phase of your experience with us to provide you with exactly the information you are looking for. Please take a minute and let us know what questions you would like answered so we can be certain to provide those.

How did you discover Novaread?

If you are comfortable with sharing how you came to discover and contact Novaread, we would truly appreciate knowing. Something as simple as teacher, friend, Google Search, AD or maybe you were walking by the office and saw the sign. It helps to know and when possible we like to say thank you to anyone who may have helped direct you our way.