AEPS Family Report II

FAMILY REPORT II

Child's name: ______________________________________________

Childs date of birth: _______________________________________

Today's date: ______________________________________________

Family's name and address: ________________________________

______________________________________________________________

Name of person completing form: ___________________________

Date of first administration: ________________________________

List child's sibling(s) and provide age(s)

______________________________________________________________

Describe your child's strengths: _____________________________

______________________________________________________________

Describe your childs special needs: _________________________

______________________________________________________________

Completion of the items and questions in this form will assist you and your family members in participating in your child's assessment, goal development, intervention, and evaluation activities. It will also help prepare you to participate in your child's individualized family service plan (IFSP)/individualized education program (IEP) meeting. The Family Report is composed of two sections. Before completing either section, you should decide if you prefer to answer the questions by yourself or with other family members or if you prefer to have assistance from a program staff member. If you have questions or concerns about how to complete either Section I or Section 2, ask a member of your team for assistance.

Note: Shaded areas are designed for use by professional staff.