Individual Child Profile Individual Child Profile Help us get to know your child. All forms are confidential and will not leave the offices of Christian Cottage. Child's Name* First Last Date of Birth* Parent Name(s)* First Last Phone*Email* Gender* Male Female Adopted?* Yes No Age at Adoption Blended Family?* Yes No When? Current Grade*Pre-K123456789101112General Attitude / Personality TraitsReluctant Learner - Excitably Curious*Please indicate on a scale of 1-5 this child's general attitudes and personality traits of Reluctant Learner to Excitably Curious. Short comments are also welcome (i.e. when around adults, when stressed, etc...). Fearful - Daring*Please indicate on a scale of 1-5 this child's general attitudes and personality traits of Fearful to Daring. Short comments are also welcome (i.e. when around adults, when stressed, etc...). Compliant - Strong-Willed*Please indicate on a scale of 1-5 this child's general attitudes and personality traits of Compliant to Strong-willed. Short comments are also welcome (i.e. when around adults, when stressed, etc...). Ambitious - Lazy*Please indicate on a scale of 1-5 this child's general attitudes and personality traits of Ambitious to Lazy. Short comments are also welcome (i.e. when around adults, when stressed, etc...). Introverted - Extroverted*Please indicate on a scale of 1-5 this child's general attitudes and personality traits of Introverted to Extroverted. Short comments are also welcome (i.e. when around adults, when stressed, etc...). Shy - Friendly*Please indicate on a scale of 1-5 this child's general attitudes and personality traits of Shy to Friendly. Short comments are also welcome (i.e. when around adults, when stressed, etc...). Self-Reliant - Dependent*Please indicate on a scale of 1-5 this child's general attitudes and personality traits of Self-Reliant to Dependent. Short comments are also welcome (i.e. when around adults, when stressed, etc...). Unmotivated - Achiever*Please indicate on a scale of 1-5 this child's general attitudes and personality traits of Reluctant Learner to Excitably Curious. Short comments are also welcome (i.e. when around adults, when stressed, etc...). Slow Learner - Quick Study*Please indicate on a scale of 1-5 this child's general attitudes and personality traits of Slow Learner to Quick Study. Short comments are also welcome (i.e. when around adults, when stressed, etc...). Competitive - Non-Competitive*Please indicate on a scale of 1-5 this child's general attitudes and personality traits of Competitive to Non-Competitive. Short comments are also welcome (i.e. when around adults, when stressed, etc...). Sharp Memory - Forgetful*Please indicate on a scale of 1-5 this child's general attitudes and personality traits of Sharp Memory to Forgetful. Short comments are also welcome (i.e. when around adults, when stressed, etc...). Distractible - Attentive*Please indicate on a scale of 1-5 this child's general attitudes and personality traits of Distractible to Attentive. Short comments are also welcome (i.e. when around adults, when stressed, etc...). Disorganized - Goal-Focused*Please indicate on a scale of 1-5 this child's general attitudes and personality traits of Disorganized to Goal-Focused. Short comments are also welcome (i.e. when around adults, when stressed, etc...). Tell us a little more about your child:When my child has free time, he/she will...*Please describe how your child interacts with others:*Briefly describe your childSchool HistorySchool history*Under School type, please use the code PR=Private School, PS=Public School, H=Homeschool. Add in as many rows as applicable to your child. *Transcripts or Report Cards are required for all classes taken in or after 9th grade. GradeName of SchoolTypeTypical Grades EarnedProblems? Praises? If homeschooling, what curriculum program was used? Upload Transcript or Report Cards for high school students Drop files here or Select files Accepted file types: jpg, gif, png, pdf, doc, Max. file size: 100 MB. Medical HistoryBirth was:*PrematureLateOn TimeCesareanBirth Weight Any complications or illnesses during pregnancy? Were there any complications or difficulties during labor and delivery? Age of first steps Age of first sentence List all major health problems to date:MedicationsList all medications currently being taken (including vitamins and supplements)Medications - long termList all medications that have been used for more than two weeks at a time (prescription and over the counter)List any allergiesHead injury? Yes No Please explain: Eye injury? Yes No Please explain: Indicate Problem AreasCheck all that apply Headaches Vision Speech or Hearing Please Explain DiagnosisPlease indicate any diagnosis/labels/disorders that have been used to describe your child. Select all that apply. ADD/ADHD Dyslexia/Reading Problems Auditory Processing challenges Learning Disability Autism Spectrum Disorder (including Asperger's) Speech/Language Disability Physical Disability Developmentally Delayed Other Learning DisabilityPlease describe: Other Academic likes/dislikesBibleWhat books have you liked/disliked?Phonics / SpellingWhat books have you liked/disliked?Reading / LiteratureWhat books have you liked/disliked?GrammarWhat books have you liked/disliked?WritingWhat books have you liked/disliked?MathWhat books have you liked/disliked?ScienceWhat books have you liked/disliked?HistoryWhat books have you liked/disliked?OtherWhat books have you liked/disliked?GoalsStrengthsWhat do you see as your child's greatest strengths? NeedsWhat do you see as your child's greatest needs? GoalsWhat are your goals for your child this year?Long Range GoalsWhat are your long range goals for your child?Phone Family Profile Enrollment Form Learning Behavior Rating Scale