The EPT Clinic's School Report Form Step 1 of 4 25% Our clinic is currently in the process of carrying out a psychology or multidisciplinary team assessment with a child which you are teaching. As part of this process, we would like to gather information on how he/she is getting on in school.This valuable information from you, the child’s teacher, adds greatly to our understanding of the child’s needs across settings.We know that schools are very busy places, so we thank you in advance for filling in this form. Please note that this information will most likely be included in the child's report and shared with their parents.The EPT Clinical TeamWhen you submit this form, it will not automatically collect your details like name and email address unless you provide it yourself.InstructionsThis form is intended to be completed by the young person’s current teacher, teaching team or a designated educational professional who works directly with the child in an academic setting. The information provided is essential for accurately assessing the young person’s educational needs and should reflect observations from an educational context.By submitting this form, the teacher/teaching team confirms that the information is accurate to the best of their knowledge, based on their professional interactions with the young person.Please complete the form to the best of your ability. If you wish to have a copy of your answers emailed to you after you complete the form, please email info@eptclinic.ie and the EPT Team will email you the completed form.Child's Name*Parent/Guardian's Name(s)*Child's Address*Child's Age*Child's Date of Birth* Day Month Year Child's Class*School Name*School Phone Number*School Address*What are your main concerns?* Learning & Academic Skills*(Reading, writing, numeracy, memory, processing) Please note strengths and needs.Communication & Language*Please note strengths and needs.Attention & Concentration*Please note strengths and needs.Behaviour & Emotional Skills*Please note strengths and needs.Relationships with Peers*How does the student interact with other students? Please note strengths and needs.Fine & Gross Motor Skills*(Writing speed, using scissors, hopping, running) Please note strengths and needs.Talents and Interests* Supports in Place In Class Support - Continuum Level 1 Learning Support (in groups) - Continuum Level 2 Learning Support (one to one) - Continuum Level 3 SNA Support Assistive Technology Movement Breaks No Support in Place Additional Comments in Relation to Supports in PlaceHave you observed any unusual, restricted, repetitive or sensory behaviours?*Further Relevant Information or Questions for the Psychologist Teacher(s) Completing this Form*Teacher Phone Number*Teacher Email* School Principal*School Principal Phone Number*School Principal Email Today's Date* Day Month Year Consent* ConfirmationI confirm that the information in this form is true to the best of my knowledge. The information is provided in good faith by teachers who know the named child.
