Jennifer Nickel

Educational Therapist

Client Information Form

Please answer each question as fully as possible. The information requested
will be kept strictly confidential, and is used only for the purpose of designing
an appropriate educational program to meet new clients needs.
Your name: ___________________________ Date:___________________
Relationship to Student: _________________________________________
Referral Source: ________________________________________________

1. Background Information
Name of Student: ________________________ Nickname: _____________
Age: ________ Date of Birth: ______________ Grade in School: ________
Students gender identity: _________________ Gender at birth: _________
Primary language spoken at home: _________________________________
Other languages spoken: _________________________________________
If English was not your students first language, when and where did your
student learn English?
_____________________________________________________________
Please list your students strengths, special interests, and hobbies.
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
In what activities and subjects has your student been particularly successful?
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

Jennifer Nickel
Educational Therapist
Please describe the reasons for seeking educational therapy for your student.
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Please describe your desired outcomes for educational therapy.

________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
Parent Information
Parent One

Parent Two

Name
Address
Phone Numbers (home,
mobile, work)
Occupation
Highest Level of
Education Completed
Describe any learning
differences or difficulties
in school, e.g. ADHD,
dyslexia, etc.

Jennifer Nickel
Educational Therapist
Parents marital status (married, divorced, widowed, remarried):
_____________________________________________________________
If remarried, which parent? _______________________________________
If parents are divorced, please describe the students living arrangements.
_____________________________________________________________

Sibling Information: Please list all siblings, including stepsiblings

Name

Relationship to
Student

Age

Grade

Learning Differences?

Please list other members of the household:

________________________________________________________
Please list all psychologists, speech and language pathologists, tutors,
educational therapists, or other professionals who have evaluated or provided
treatment for your student.

Name

Profession

Date(s) of Treatment

________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________

Jennifer Nickel
Educational Therapist

2. School History
Please list all schools attended.
Preschool: ____________________________________________________
Elementary School: _____________________________________________
Middle School: _________________________________________________
High School: __________________________________________________
School currently attending: _______________________________________
Teacher(s): ______________________________________________
Has your student ever repeated a grade? If so, please explain:
_____________________________________________________________
Has your student ever received special services in school, including special
education services? If so, please describe, including the dates of service:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Age at which you started to suspect learning problems: _________________
Age at which school-related problems were identified: __________________
Has the school indicated that your student is below grade level in any
academic area? If so, please describe:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

Jennifer Nickel
Educational Therapist
What are your students feelings about school?
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Does your child have friends at school? _____________________________
Do any of the following describe your student? Check all that apply:
___ has trouble completing assignments on time
___ forgets to turn in assignments
___ spends excessive time on homework
___ has trouble getting started on assignments
3.

Medical Background

Does your student have any medical conditions for which they are currently
being treated? If so, please describe.
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Is your student currently taking any prescription medications? If so, please
describe.
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Has your student missed significant amounts of school for any reason? If so,
please describe.
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Has your student been diagnosed with attention deficit hyperactivity disorder
(ADHD)? If so, please state age of diagnosis and any medications student is
currently taking for this disorder.
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

Jennifer Nickel
Educational Therapist
Please check any of the following conditions that your student has had, and
age at which it occurred:
____ Multiple ear infections (before age 5) __________________________
____ Head injury with concussion or loss of consciousness ______________
____ Chronic headache or migraines _______________________________
____ Seizures _________________________________________________
Date of last hearing test ________________ Tested by _________________
Date of last vision check ________________ Tested by _________________
Does your student wear glasses? If so, please describe when glasses are
required.
_____________________________________________________________
Has your student been evaluated by a developmental optometrist? If so,
please give date(s) of evaluation and summarize significant findings.
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Please use this space to provide any additional information you would like to
me have about your student.