PPPS

BASIC STUDENT INFORMATION

Student Legal Name

First Name

Last Name

Student Date of Birth

Must contain a date in MM/DD/YYYY format

Student Grade

Name of Student's Private School

Student Home Address

Student's Gender

Female

Male

Prefer Not to Answer

Other

Student's Race

White/Caucasian

Black/African American

Multiracial

Student's Ethnicity

Non-Hispanic

Hispanic

Student's Native Language

Student's Native Country

How long has the student lived in the United States?

What language is most spoken at home?

Parent/Legal Guardian 1 - Name

First Name

Last Name

Parent/Legal Guardian 1 - Phone Number

Parent/Legal Guardian 1 - Email Address

Parent/Legal Guardian 2 - Name

First Name

Last Name

Parent/Legal Guardian 2 - Phone Number

Parent/Legal Guardian 2 - Email Address

PERSON COMPLETING THIS FORM

Name of Person Completing this Form

First Name

Last Name

STUDENT STRENGTHS

Please list your child’s strengths. Please consider academic, behavioral, social, and practical skills.

Please describe your child's interests and activities, both individual and group, or community-based.

Who are the people your child turns to for support when needed?

Which activities help your child cope with stress?

What chores or jobs does your child complete?

What do you enjoy most about your child?

CONCERNS

What are your main concerns about your child at this time?

What do you find most difficult about raising your child?

What else do you think would be helpful for your child's team to know?

What outcomes are you hoping to obtain from this process?

BIRTH HISTORY

What was your child’s weight at birth?

Please indicate any complications during pregnancy or delivery.

How many days did your child remain in the hospital following delivery?

Is there any family history of difficulties related to speech, language, or learning? With emotions, behavior, or attention?

EARLY DEVELOPMENT

Please list any concerns or delays in your child’s early development (e.g., sitting, standing, walking, speaking, toilet training).

During the first few years, please describe your child’s temperament.

MEDICAL HISTORY

Does your child have any medical diagnoses? If so, you may share medical information to be considered as part of this process.

Are there any concerns related to your child's vision? If yes, please explain.

Has your child passed a recent vision screening?

Are there any concerns about your child's hearing? If yes, please explain.

Has your child passed a recent hearing SCREENING?

Yes

No

Screening Not Yet Completed

If you checked one of the options above, please elaborate. At what ages did these occur?

Please indicate all chronic health concerns or physical conditions (e.g. allergies, asthma, ADHD, headaches, diabetes, etc.).

Please list all current medications and how often they are taken.

FAMILY/SOCIAL HISTORY

Please list all adults who live with your child (and their relationship to your child)

Please describe how your child usually gets along with adults in the home.

Has your child ever experienced parental separation, divorce, or death?

Yes

No

Are there any custody or guardianship agreements in place for your child?

Please list all children who live with your child (and their relationship to your child).

Describe how your child usually gets along with other children in the home.

Describe discipline techniques in the home:

Do all caregivers agree?

Yes

No

Has this child ever experienced abuse or neglect?

Yes

No

SCHOOL HISTORY

Please list all schools your child has attended, including preschool/daycare and dates attended.

Has your child ever skipped a grade in school?

Yes

No

Has your child ever repeated a grade in school?

Yes

No

Has your child ever been tested for Special Education?

Yes

No

If your child has been tested for Special Education, when was their evaluation?

SUPPORT SERVICES

Please check any services your child has ever received OUTSIDE of school:

If you checked one of the options above, please elaborate. What are the names of the providers, and what dates did your child receive those services?

OTHER PREVIOUS EVALUATIONS

If your child has had evaluations outside the Brandywine School District, we encourage you to share them with our team to consider as part of the screening and evaluation process. Please email any reports you would like to share to our coordinator (Amanda.Scarborough@bsd.k12.de.us). Examples include:

Out-of-state educational evaluations
Private psychological, neurological, or psychiatric evaluations
Medical evaluations regarding conditions that may affect education
Occupational or physical therapy evaluations
ADHD evaluations

Please upload any files you would like to share with our team.

Attach up to 5 files with a maximum size of 10MB

No file chosen

Terms of Service

I agree to the Terms of Service ***I can put any language here that you would like***

Toggle Close Container

Menu Search

Desktop Main Nav

Mobile Search

District Home Link

District Schools Mobile

Mobile Main Nav

Mobile Utility

Translate

Header Holder

Header Bar Announcement

Header Bottom

Header Logo

Header Right Column

District Home Link

District Schools Desktop

Utility Nav Desktop

Translate

Desktop Search

Toggle Menu Container

horizontal-nav

In This Section

Breadcrumb

Child Find Online Referral Form for School-Aged (K-12) Parentally-Placed Private or Homeschooled Students

BASIC STUDENT INFORMATION

PERSON COMPLETING THIS FORM

STUDENT STRENGTHS

CONCERNS

BIRTH HISTORY

EARLY DEVELOPMENT

MEDICAL HISTORY

FAMILY/SOCIAL HISTORY

SCHOOL HISTORY

SUPPORT SERVICES

OTHER PREVIOUS EVALUATIONS