Learning Skills Rating Scale Learning Skills Rating Scale Indicates problem areas that you see in your child. Name* First Last Date of Birth* MM slash DD slash YYYY Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Parent's Name(s)* First Last Phone*Email* Problem AreasIndicate any problems in the following areas. Check all that apply. Reading Writing Math Spelling Comprehension Avoidance of school work Works too hard Slow work Reversals of letters or words Loses place/skips lines Poor memory Attention/Concentration Motivation/behavior Low self-esteem Overly Active Other Other: Help utilizedPlease list any past or current help, training or tutoring utilized for the above problems. Learning Skills Rating ScalePlease read each of the following statements and rate this individual according to the following scale. 4=defining characteristic, THAT'S MY CHILD! 3=happens on and off, 2= sometimes, 1=rarely, 0= not at all.1. Distracted from the task at hand*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 2. Reading is slow*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 3. Poor reading or comprehension*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 4. Often asks to have things repeated*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 5. Has difficulty maintaining attention*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 6. Slow, deliberate speech*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 7. Makes spelling errors in written assignments*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 8. Has difficulty remembering telephone numbers*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 9. Has difficulty organizing activities*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 10. Completes math assignments slowly*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 11. Has difficulty sounding out unknown words*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 12. Needs to look multiple times when copying*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 13. Has difficulty doing two things at once*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 14. Takes a long time to complete tasks*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 15. Oral reading is slow or choppy*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens onn & off 4 - defining characteristic 16. Has difficulty following verbal directions*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 17. Avoids prolonged mental effort*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 18. Generally does things slowly*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 19. Needs words repeated when taking spelling tests*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 20. Has difficulty recalling stories and jokes*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 21. Has difficulty remembering things just heard*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 22. Is often one of the last to complete tasks*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens onn & off 4 - defining characteristic 23. Avoids reading*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristics 24. Gets poor test results when being tested for facts*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 25. Is impulsive*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 26. Avoids or has difficulty with video games*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 27. Has difficulty finding words for verbal expression*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 28. Needs to restudy or reread materials*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 29. Has poor study or work habits*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 30. Writing assignments take too long*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 31. Has difficulty reading or spelling phonetically*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 32. Has problems remembering names*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 33. Poor sense of direction/map reading skills*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defiining characteristic 34. Poor math grades or test scores*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 35. Has poor handwriting*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 36. Swears or uses obscene language*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 37. Jigsaw puzzles are difficult or avoided*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 38. Has difficulty understanding stories or jokes*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 39. Squints, blinks, or rubs eyes when reading*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 40. Loses temper*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 41. Misreads similar words*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 42. Thoughts and materials are poorly organized*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 43. Has difficulty hearing*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 44. Argues with authority figures*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 45. Poor at or dislikes drawing*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 46. Poor at or avoids games like chess or checkers*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 47. Has poor coordination*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 -defining characteristic 48. Refuses requests or disobeys rules*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 49. Has difficulty with math word problems*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 50. Has problems seeing the "big picture"*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 51. Has speech difficulties*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 52. Deliberately does things that annoy others*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 53. Has difficulty creating pictures in the mind*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 54. Takes a while to catch on to new things*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 55. Complains about eye strain or fatigue*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 56. Blames others for mistakes*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 57. Lacks creativity or imagination in writing*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarerly 2 - sometimes 3 - happens on & off 4 - defining characteristic 58. Doesn't like card games*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 59. Is bothered by loud sounds*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 60. Is angry and resentful*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 61. Poor at problem solving*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristivc 62. Has difficulty planning steps to solve problems*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 63. Skips words or lines when reading*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic 64. Holds grudges or seeks revenge*Compared to others of the same age and gender, this behavior: 0 - not at all 1 - rarely 2 - sometimes 3 - happens on & off 4 - defining characteristic Individual Child Profile Family Profile Enrollment Form