APPLICATION FORM

To be sent with recent evaluations and a VHS video of your child

 

 

Please type or print

 

Student Information

 

Student’s full name: ________________________________________________________________________________________________

                                 Last                                                                                  First                                                   Middle

 

Sex: ___________            Date of Birth: _____________ Current age: ____________

 

Current address: ___________________________________________________________________________________________________

                                                                    Street                                                   City          State                          Zip code

 

Parent Information

 

(1) Parent/Guardian name: ___________________________________________________________________________________________

Last                                                                              First                                                                              Middle

 

Relationship to child: ________________________________________________________________________________________________

 

Home Phone: __________________________                                       

 

Occupation: __________________________________ Work Phone: ____________________________

 

Work Address: _______________________________________________________________________

 

(2) Parent/Guardian name: ___________________________________________________________________________________________

Last                                                                              First                                                                              Middle

 

Relationship to child: _____________________

 

Home Phone: __________________________                                       

 

Occupation: __________________________________ Work Phone: _______________

 

Work Address: ______________________________________________________________________

 

What is the primary language spoken at home? ________________

 

Who referred you to the Birchtree Center for Children? _____________________________

History and Current Status

 

Diagnosis performed by: ________________________________________________________________

 

Clinical diagnosis: ___________________________________ Date of diagnosis: ________

 

Does your child have a secondary diagnosis and/or any other medical conditions? ______________________________________________

 

_______________________________________________________________________________________________________________

 

Is your child currently enrolled in a school/program? ___________

 

If yes: Name of school/program: ____________________School district: _____________

 

Special Education Director: _____________________________

 

Program description: ______________________________________________________________________________________________

 

If no: Is your child currently on a waiting list? ___________

 

School(s) s/he is on a waiting list for: _________________________________________________________________________________

 

Do you have a private therapist or home program? _____________ If yes, describe: _____________________________________________

 

________________________________________________________________________________________________________________

 

Regarding placement

 

Have you requested an out-of-district placement at an IEP meeting? _______

 

Do you expect tuition to be covered by your school system or will placement be funded privately?

 

_______________________________________________________________________________________________________________

 

Additional comments: _____________________________________________________________________________________________

 

 

 

Signature of parent or guardian: ______________________________

                                                                                                                

Date: ______________________________

 

 

 

Materials submitted:

 

ÿ              Application Form

ÿ              Videotape of your child (directions on page 3)

ÿ              Recent evaluations of your child (explanation on page 3)

 

The Birchtree Center admits students of any race, color, and national ethnic origin.

 

ADDITIONAL APPLICATION MATERIALS

 

 

 

 

Videotape

 

Please submit a minimum of ten (10) minutes of video footage of your child. Videotape 5-10 minutes of your child in a structured learning setting, as well as 5-10 minutes of your child in an unstructured setting (for example, playing, interacting with family and/or friends, and/or participating in daily activities).

 

 

 

 

 

Evaluations

 

Please submit copies of your child’s most recent I.E.P. (Individual Education Plan) and most recent evaluations. Examples of pertinent evaluations include, but are not limited to: Neurological, psychological/psychiatric, speech and language, occupational therapy, medical.

 

 

 

 

 

 

 

 

Please send all materials to:

 

Christine Guarino, Ph.D., CCC-SLP

The Birchtree Center

33 Jewell Court, Suite 2

Portsmouth, NH 03801