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Please fill out this form to the best of your knowledge, the information we gather is vital to providing the most effective therapy programme.

You will have an ID Code in the email sent to you.

Academic Profile

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Meeting age expectations in....
Phonics Screening Test
Pass
Fail
n/a
Overall Academic Progress
Expected
Below Expected
Significantly Below Expected
Key concerns raised by teaching staff

Standardised Scores (if applicable)

Observations of visual learning

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How would you describe the child's copying ability?
Observed reading behaviours (tick all that apply)
Visual presentation of work

Motor Observations

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How is the child's general co-ordination (e.g. P.E or playground)
Age Appropriate
Slight difficulties
Significant difficulties
How are the child's fine motor abilities? (e.g. Scissors and handwriting)
Age Appropriate
Below Expectations

Behavioural Observations

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1 star = very poor, 2 = poor, 3 = average, 4 = good, 5 = very good

Interventions and adjustments

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Referrals

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Screening Tests

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Tests Performed

Other

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