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DHH Child Admission Screening Form
DHH Child Admission Screening Form
Parent/Guardian Information:
- Parent/Guardian Name(s):_________________________- Contact Information:__________________
- Preferred Mode of Communication (e.g., sign language, spoken language):______________________
Hearing Assessment:
- Date of Most Recent Hearing Assessment:____________ - Degree of Hearing Loss:_______________
- Type of Hearing Loss:_____________________________ - Hearing Devices (if any):_______________
- Audiologist's Recommendations:________________________________________________________
Communication Modality:
- Primary Mode of Communication:___________________- Proficiency Level in Chosen Mode:_______
- Secondary Mode of Communication:_________________- Proficiency Level in Secondary Mode:_____
Educational History:
- Previous School(s):____________________________________________________________________
- Special Education Services Received:_________________- Accommodations Provided (if any):_______
- Current or Past Individualized Education Plan (IEP) Information:________________________________
Social-Emotional Development:
- Social Interaction Observations:
Initiating and maintaining eye contact.
Engaging in turn-taking during conversations or activities
Responding to verbal and non-verbal cues from peers and adults.
Demonstrating active listening skills.
Demonstrating appropriate body language and gestures.
Engaging in cooperative play or group activities.
Demonstrating empathy and understanding of others' emotions.
Cognitive Abilities:
Orientation: [e.g., Oriented to time, place, and person]
Memory: [e.g., Immediate, short-term, long-term memory]
Attention and Concentration: [e.g., Able to focus, distractible]
Abstract Thinking: [e.g., Able to understand abstract concepts]
Insight: [e.g., Awareness of current situation and condition]
- Cognitive Assessment Results (if available):________________________________________________
- Identified Intellectual Strengths or Weaknesses:____________________________________________
Adaptive Behavior:
- Daily Living Skills (e.g., self-care, independence):____________________________________________
- Adaptability in Different Environments:___________________________________________________
Psychological:
- Identified Emotional or Behavioral Concerns (if any):_________________________________________
Family Input:
- Parent/Guardian's Perspective on Child's Development and Needs:_____________________________
Health Assessment:
- Relevant Health Conditions:______________________- Health-Related Accommodations or
Considerations:________________________________________________________________________
Educational Goals:
- Expectations of Parents/Guardians about child education:____________________________________
Support Services:
- Identify Necessary Support Services, Accommodations, and Interventions:_______________________