Erin Powers -Information Form

Erin Powers M.Ed BCET
Educational Therapist
Board Certified
650-644-7463
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erin
powers
learning

Because All Children Have The Desire,
The Will And The Ability To Learn

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Information Form

To be completed by parents or guardian of a student.

A printable version of this form is available here (pdf)

STUDENT CONTACT INFORMATION

Student's Full Name

Student's Address

Student's Email Address

Student's Home Phone

Student's Cell Phone

STUDENT SCHOOLING INFORMATION

Student's Age

Grade

Birthdate

Has student skipped a grade?

Which grade skipped?

Has student repeated a grade?

Which grade repeated?

Name of school now attending

Previous schools

PARENTAL INFORMATION

Father's name

Father employed by

Father's occupation

Father work phone

Mother's name

Mother employed by

Mother's occupation

Mother's work phone

MARITAL STATUS

Are both parents living with the child?

Yes

Are parents separated or divorced?

Separated

Divorced

Neither

If divorced, has either parent re-married?

Yes

STUDENT COUNSELING / TESTING / MEDICATION

Is the student receiving counseling?

Yes

If yes, with whom?

Has the student had educational and/or pschological testing?

Yes

If yes, when?

What types of evaluation?

If on medications, name of prescribing doctor

Current medications

COMPLETE AND SUBMIT FORM

Name of person completing this form

Email address

By checking here, you confirm that you are the parent or guardian of the student

Erin Powers - Educational Therapist - 1 650 644 7463 - erin.edtherapist@gmail.com

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