GOALS AND SYMPTOMS This field is hidden when viewing the formUUIDThis field is hidden when viewing the formDoc IDClient Name First Last Date MM slash DD slash YYYY This field is hidden when viewing the formevaluationHANDWRITINGAvoids coloring or drawing Never Rarely Sometimes Often Has messy handwriting Never Rarely Sometimes Often Inconsistent spacing between words Never Rarely Sometimes Often Mixes uppercase and lowercase letters Never Rarely Sometimes Often Reverses letter numbers often Never Rarely Sometimes Often Dislikes writing Never Rarely Sometimes Often Rushes through handwriting tasks Never Rarely Sometimes Often Doesnt erase mistakes Never Rarely Sometimes Often Frequently rewrites work Never Rarely Sometimes Often Writes short answers despite knowing more Never Rarely Sometimes Often Takes a long time to complete homework Never Rarely Sometimes Often Holds pencil in an unusual way Never Rarely Sometimes Often Complains of hand pain or fatigue when writing Never Rarely Sometimes Often Grades are affected by handwriting quality Never Rarely Sometimes Often Moves mouth when writing Never Rarely Sometimes Often Poor writing posture Never Rarely Sometimes Often COORDINATIONStruggles with ball games Never Rarely Sometimes Often Is this a skill you would like to address? (1) Yes No Difficulty riding a bike Never Rarely Sometimes Often Is this a skill you would like to address? (2) Yes No Trouble tying shoelaces Never Rarely Sometimes Often Is this a skill you would like to address? (3) Yes No Difficulty with movements like galloping hopping or skipping Never Rarely Sometimes Often Trouble with dressing Never Rarely Sometimes Often Often bumps into objects or people Never Rarely Sometimes Often Struggles with tasks that require hand-eye coordination Never Rarely Sometimes Often Appears uncoordinated Never Rarely Sometimes Often VISUAL SKILLSLoses place when reading or uses finger to keep track Never Rarely Sometimes Often Moves the entire head instead of eyes when reading Never Rarely Sometimes Often Finds it hard to copy from the board book Never Rarely Sometimes Often EMOTIONAL RESPONSESHas difficulty managing emotions Never Rarely Sometimes Often Appears anxious compared to peers Never Rarely Sometimes Often Feels insecure Never Rarely Sometimes Often Has a fight or flight response Never Rarely Sometimes Often Has frequent meltdowns Never Rarely Sometimes Often Shows anger or aggression Never Rarely Sometimes Often Struggles with showing or receiving affection Never Rarely Sometimes Often Acts impulsively Never Rarely Sometimes Often Has trouble adapting to changes Never Rarely Sometimes Often Appears fearful Never Rarely Sometimes Often SENSORYSensitive to noise Never Rarely Sometimes Often Sensitive to light Never Rarely Sometimes Often Sensitive to touch Never Rarely Sometimes Often Bothered by textures tags in clothing Never Rarely Sometimes Often Finds waistbands in pants uncomfortable Never Rarely Sometimes Often ATTENTIONFidgets a lot Never Rarely Sometimes Often Easily distracted Never Rarely Sometimes Often Has trouble sitting still Never Rarely Sometimes Often Appears hyperactive Never Rarely Sometimes Often SOCIAL RESPONSESAvoids making eye contact Never Rarely Sometimes Often Is shy Never Rarely Sometimes Often Feels uncomfortable in social situations Never Rarely Sometimes Often Appears immature Never Rarely Sometimes Often ADDITIONAL INFORMATIONBites nails Never Rarely Sometimes Often Bed wetting poor bladder control beyond age 5 Never Rarely Sometimes Often Has trouble sleeping Never Rarely Sometimes Often Please list goals for S2S programAdditional information you’d like to share Δ
S2S FormsS2S Forms