Landmark School · 2020. 10. 30. · Landmark School, Office of Admission, 429 Hale Street, PO Box 227, Prides Crossing, MA 01965-0227. Diagnostic Testing Requirements In order to

Landmark School

Application for Admission

Embracing Potential. Empowering Lives. Educating students with language-based learning disabilities.

www.landmarkschool.org

Welcome to the Admission Process

Please read the following guidelines and informationprior to completing the Application for Admission.

• We encourage all families to participate in a virtual Informational Visit and Campus Tourwww.landmarkschool.org/admission/visit-landmark

• Complete this modifiable Application for Admission and submit via email [email protected] You will find instructions for utilizing modifiable PDF's on theApply to Landmark section of our website.

• Submit PDF's of required documentation (see list below) via email to [email protected]

• Submit a recent photo of applicant via email to [email protected]

• PLEASE NOTE: We request that you send each item as an individual PDF document

• You will be contacted by a member of the Admission Team at various stages in the application processto let you know what has been received and/or what is outstanding, if a completed application is beingreviewed, or if we are ready to set up a virtual interview/screening (as needed) in order to make a finaldetermination regarding acceptance.

Required Items:

Pages 1-11 of the Application for Admission

Recent photo of the applicant

Application Fee of $150.00 ($175.00 for international students) to be mailed to:Landmark School / Office of Admission, PO Box 227, Prides Crossing, MA 01965-0227

Summer Program Selection form (if applicable),www.landmarkschool.org/admission/apply-landmark or by request via email

All diagnostic testing completed within the past three years

Official School Records for the past two years, including report cards, transcript(s), IEP/504s,and Progress Reports if applicable

Reference and Service Provider forms provided in the Application for Admission (see page 12)

NOTE: International students must have an F1/student visa

We are requesting that all applications and documentation be submitted via email to [email protected] you are unable to do so, please send via mail to: Landmark School, Office of Admission, 429 Hale Street, PO Box 227, Prides Crossing, MA 01965-0227

Diagnostic Testing Requirements

In order to consider your child’s application, Landmark School requires a full narrative report that indicates the presence of a language-based learning disability. This evaluation must have been administered

within the past three years. The following measures are required:

I. Cognitive Assessment: Wechsler IQ Scales

Full WISC-IV or WISC-V (Wechsler Intelligence Scale for Children) for students age 16 and underorFull WAIS-IV (Wechsler Adult Intelligence Scale) for students age 16 +

Please note that the WASI (Wechsler Abbreviated Scale of Intelligence) is not acceptable as a substitute for the WISC-V or WAIS-IV.

To the Evaluator: All index scores as well as all subtest scaled scores are required. Landmark requests the Digit Span subtest to be reported as Digit Span forward and backward.

II. Academic Achievement Testing

WIAT III (Wechsler Individual Achievement Test) or Woodcock Johnson Tests of Achievement, version III or IVor Kaufman Test of Educational Achievement/Third Edition (KTEA-3)orother similar measures of academic achievement

III. Assessment of Psycho-Social Functioning

BASC-2 (Behavioral Assessment Scale for Children) or CBCL (Child Behavior Checklist) or other similar measures of psycho-social functioning

Please note: Any additional testing that has been administered within the past three years (such as speech and language or occupational therapy

evaluations) must be submitted along with your application.

Thank you.

Application for Admission Landmark School

Academic Year Application Yes No Starting Year of Interest: __________-__________

Summer Program Application Yes No Year of Interest: ____________________

Please choose one: Day Boarding Undecided NOTE: Boarding is available for students entering Grade 9 and above for Academic Year, or Grade 8 and above for summer programs.

Date of Application___________________ Applying for grade_________ Current grade__________

Applicant’s Legal Name_____________________________________________________(__________) First Middle Last Preferred Name

Address_____________________________________________________________________________ No./Street City/Town State Zip

Primary Phone__________________ Applicant’s Gender_____________________ Current Age_______

Date of Birth_________ Country of Citizenship*______________ Country of Birth________________

Ethnicity (optional)_________________Primary language if other than English____________________

*If Citizenship is other than U.S., does student have a Green Card? Yes No (check one)

*If Citizenship is other than U.S., does student have an F1/student visa? Yes No (check one)

Page 1

Primary Parent/Guardian

(this person will be the primary contact for emails, forms, contracts, etc.)

Name___________________________________Mr. /Mrs./Ms./Dr. First

MI Last

Preferred Name_________ _____________________ __________________________________ Relationship to Applicant

Check if deceased Date_____________________

Date of Birth________________________________

Home Address (if different from Applicant)

___________________________________________

___________________________________________

Primary Phone_______________________________

Primary Email_______________________________

School/College______________ Degree__________

Employer___________________________________ Name of Company Type of Industry

____________________________________________ Your Position/Title Business Phone

____________________________________________ Business Address (Street, City, State, Zip, Country)

Name______________________________________

Mr./Mrs./Ms./Dr. First MI Last

Preferred Name______________________________

__________________________________ Relationship to Applicant

Check if deceased Date_____________________

Date of Birth________________________________

Home Address (if different from Applicant)

___________________________________________

___________________________________________

Primary Phone_______________________________

Primary Email_______________________________

School/College______________ Degree__________

Employer___________________________________ Name of Company Type of Industry

____________________________________________ Your Position/Title Business Phone

____________________________________________ Business Address (Street, City, State, Zip, Country)

Parent(s) are Single Married Life Partners Divorced Separated Father Remarried Mother Remarried

Name(s) of Step-parent(s)______________________________________________________________________

With whom does the applicant reside?____________________________________________________________

Legal guardian(s)____________________________________________________________________________

NOTE: If applicable, parents may be asked to provide custody documents if student is accepted to Landmark School.If parent(s)/guardian(s) are not living at the same address, do we have permission to communicate with both parents/guardians throughout the admission process? no yesIf no, all correspondence will be directed to the primary contact as noted above.

Is the applicant adopted? no yes Is the applicant aware of the adoption? no yes

Names and ages of siblings:_____________________,________________________,______________________

Page 2

Please check all applicable columns below Grade Year Please list all schools that the applicant

has attended from grade K to present: Public Private Day Boarding IEP Private

Tutor

K -

1 -

2 -

3 -

4 -

5 -

6 -

7 -

8 -

9 -

10 -

11 -

12 -

If student is not in school, please state reason._________________________________________________________

_____________________________________________________________________________________________

Has the applicant ever been suspended or expelled from school? If so, include school reports documenting the date(s) and reason(s) for disciplinary action(s).

Who referred you to Landmark, or how did you hear about our programs?

Name_____________________________________Organization________________________________________

Profession (e.g. diagnostician, consultant, advocate, physician, educator)____________________________________

Address_____________________________________________________________________________________

Phone_______________________Email___________________________________________________________

Page 3

MEDICAL INFORMATION

Physician’s name______________________________________ Phone______________________________

Please list all your child’s diagnoses (educational, psychological, medical). By whom and when?

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Please list medical conditions, if any.

_________________________________________________________________________________________

_________________________________________________________________________________________

Is your child currently receiving any medication(s)? No Yes

If yes, please list medication(s), start date(s), diagnoses, prescribing physicians, and describe condition(s) for which medication is being taken.

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Has your child ever received psychological counseling or therapy, either in their school setting or privately? No Yes

If counseling services have been provided within the past two years, please have provider complete the Summary of Counseling form included in this packet.

Has your child ever been hospitalized for psychological reasons? No Yes

If you answered yes to either question, please complete the following:

Provider_____________________________________Email_________________________________________

Phone___________________________________Date(s)____________________________________________

Reason(s)__________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Page 4

TUITION PAYMENT INFORMATION

Intend to pay tuition privately

Intend to seek funding from our school district, but will pay privately if funding is not approved

Intend to seek funding from our school district

Intend to apply for financial aid

FINANCIAL AID

Landmark School utilizes the School and Student Service by NAIS to analyze applications for financial aid. While the Landmark School financial aid program is modest, it does provide some assistance to those

parents/guardians who demonstrate clear financial need.

Families can apply for financial aid by visiting http://www.landmarkschool.org/admission/affording-landmark

Inquiries about financial aid should be directed to: Jodi Bertolino

Landmark School Business Office 978.236.3206

[email protected]

Page 5

RECORDS INFORMATION

In order to expedite the application process, please list the names of service providers whose information will be part of this application.

Diagnostic Tester _________________________________________Phone____________________

Email_________________________________________________________

Diagnostic Tester _________________________________________Phone____________________

Email_________________________________________________________

English Teacher _________________________________________ Phone_____________________

Email__________________________________________________________

Math Teacher ____________________________________________ Phone____________________

Email__________________________________________________________

Principal or Guidance Counselor _____________________________ Phone____________________

Email__________________________________________________________

Tutor __________________________________________________ Phone____________________

Email__________________________________________________________

Specialist________________________________________________Phone____________________

Email_________________________________________________________

Residential Advisor _______________________________________ Phone____________________

Email__________________________________________________________

Therapist/Counselor (psychological counseling)______________________Phone________________

Email__________________________________________________________

Psychopharmacologist (re: medications)____________________________Phone________________

Email__________________________________________________________

Page 6

PARENT/GUARDIAN STATEMENT

For_____________________ Completed by__________________________ Date___________ Full name of Applicant Name of Parent/Guardian

Please answer the following questions so that we may have a parent/guardian perspective on the strengths and needs of your child. Feel free to attach additional sheets.

1. What are your child’s chief strengths and interests?_________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

2. What are your child’s areas of greatest need?______________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

3. How do you hope Landmark will help your child?__________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

4. Please describe your child’s level of independence in daily life with regard to personal hygiene, room

maintenance, and household chores.________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

5. Are there additional areas of concern of which we should be aware?

_____________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________

Page 7

Strengths and Difficulties Questionnaire

For each item, please mark the box for Not True, Somewhat True, or Certainly True. It would help us if you answered all items as best you can even if you are not absolutely certain. Please give your answers on the basis of this young person’s behavior over the last six months or this school year.

Young person’s name_________________________________________ Male / Female

Date of Birth___________________________________ Not

True

Somewhat

True

Certainly

True

Considerate of other people’s feelings

Restless, overactive, cannot stay still for long

Often complains of headaches, stomach-aches or sickness

Shares readily with other youth, for example book, games, food

Often loses temper

Would rather be alone than with other youth

Generally well behaved, usually does what adults request

Many worries or often seems worried

Helpful if someone is hurt, upset or feeling ill

Constantly fidgeting or squirming

Has at least one good friend

Often fights with other youth or bullies them

Often unhappy, depressed or tearful

Generally liked by other young people

Easily distracted, concentration wanders

Nervous in new situations, easily loses confidence

Kind to younger children

Often lies or cheats

Picked on or bullied by other young people

Often volunteers to help others (parents, teachers, children)

Thinks things out before acting

Steals from home, school or elsewhere

Gets along better with adults than with other young people

Many fears, easily scared

Good attention span, sees tasks through to the end

Signature________________________________________________ Date_______________________

Parent / Teacher / Other (Please specify)__________________________________________________

Thank you very much for your help © Robert Goodman, 2005 Page 8

[email protected]

PERMISSION to RELEASE INFORMATION PERMISSION TO CONTACT

I am the parent/guardian of a child applying for admission to Landmark School. I request that all pertinent information concerning my child’s medical, psychological, and academic history be forwarded to the Landmark School Admission Office. These records include, but are not limited to, academic records, medical records, psychological evaluations, speech and language evaluations, and neuropsychological evaluations.

I give permission for Landmark School to contact all service providers for any additional information.

Landmark School Office of Admission

PO Box 227 429 Hale Street

Prides Crossing, MA 01965-0227 [email protected]

Phone 978.236.3000 Fax 978.927.7268

Full Name of Applicant___________________________________________________

Date of Birth___________________________________________________________

Street Address__________________________________________________________

City/State/Zip Code_____________________________________________________

Phone_________________________________________________________________

Signature of Parent or Guardian_____________________________________________

Date__________________________________________________________________

This release shall remain effective from the date above until such time as I revoke consent in writing or my child’s enrollment at Landmark School ceases.

Page 9

The Landmark School (Landmark) does not discriminate on the basis of race, ethnicity, religion, sexual orientation, homelessness, color, national origin, gender, gender identity, genetic information, disability, sex, or age in treatment or employment at Landmark, admission or access to Landmark, or any other aspect of the educational programs and activities that Landmark operates.

Landmark is required by Title VI of the Civil Rights Act of 1964 (Title VI), Section 504 of the Rehabilitation Act of 1973 (Section 504), Title IX of the Education Amendments of 1972 (Title IX), the Age Discrimination Act of 1975 (Age Act), and their respective implementing regulations at 34 C.F.R. Parts 100, 104, 106 and 110, not to discriminate in such a manner. Inquiries concerning the application of each of these statutes and their implementing regulations to Landmark may be referred to the U.S. Department of Education, Office for Civil Rights, at (617) 289-0111 or 5 Post Office Square, 8th Floor, Boston, MA 02109-3921, or to the applicable Landmark Coordinator:

Title VI Coordinator Susan Tomases, 978-236-3369, 429 Hale Street, Prides Crossing MA 01965

Section 504 Coordinator Susan Tomases, 978-236-3369, 429 Hale Street, Prides Crossing MA 01965

Title IX Coordinator(s) Libby Parker, 978-236-3213, 429 Hale Street, Prides Crossing MA 01965

Age Act Coordinator(s) Susan Tomases, 978-236-3369, 429 Hale Street, Prides Crossing MA 01965

If you have any questions or need more information please contact Dan Ahearn, Assistant Head of School, [email protected].

Page 10

ADMISSION POLICIES AGREEMENT

I hereby make application to Landmark School for the following student:

_______________________________________________________________ (Full Name of Applicant)

I agree to payment of the non-refundable application fee of $150.00 (domestic), $175.00 (international). U.S. dollars only; checks made payable to LANDMARK SCHOOL and sent to:

Landmark School Office of Admission PO Box 227 429 Hale Street Prides Crossing, MA 01965-0227

If the applicant has experienced physical or mental health issues which have necessitated the use of medication or therapeutic intervention, it is of utmost importance that this be indicated and described at the time of application. This information will allow us to determine the applicant’s needs more effectively. Withholding such information can only jeopardize the applicant’s well-being and deter from the school’s ability to handle any problems that may arise.

If it is determined that any critical information has been either intentionally or inadvertently withheld, Landmark School reserves the right to withdraw a student’s acceptance or terminate placement. Information pertinent to the student’s application will be held in strictest confidence and will be destroyedin five years from its receipt if the child does not attend. Please note that Landmark School's Policies andProcedures Manual is available for public review at www.landmarkschool.org

_______________________________________________________________ Parent or Guardian’s Signature Date

Page 11

The following application forms are to be completed by people who provide services directly to the applicant

(ie: teacher(s), counselor, primary care physician).

Also included is a STUDENT STATEMENT form for the applying student to complete in their own handwriting.

Choose the forms that are applicable to your child.

If your child is Elementary grade level, please have both English and Math reference forms completed, even if your child has the same teacher

for both subjects, as each form contains important information.

Please distribute these forms to the appropriate individuals for completion, and ask them to return the completed form directly to

Landmark School (email, fax, and mailing address are provided on each form --- email is preferred!)

For questions regarding these forms, please contact [email protected]

Page 12

[email protected] Fax 978.927.7268

P.O. BOX 227 • PRIDES CROSSING, MASSACHUSETTS • 01965 • 978-236-3010 • LANDMARKSCHOOL.ORG

PRINCIPAL or SCHOOL GUIDANCE COUNSELOR REFERENCE

Full Name of Student/Applicant_____________________________________ Date of Birth___________

The student named above has applied to Landmark, a school for students with language-based learning disabilities. You have been chosen bythe parent/guardian/student to provide a reference for this student. Your comments will remain confidential and will not become part of the

student record. Completion of this form does not sanction the student’s application to Landmark School.

1. How long have you known this student?_____________________________________________________

2. Is this student a positive and productive member of the school community? Yes No Please describe

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

3. Does this student engage in appropriate social interactions with peers and teachers? Yes No Please describe _______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

4. Has this student had any problems with discipline, or been suspended? Yes No If yes, please describe _______________________________________________________________________________________

_______________________________________________________________________________________

5. Additional comments____________________________________________________________________

_______________________________________________________________________________________

ACADEMIC TRAITS

Go

od

Aver

age

Po

or

Academic Motivation

Study Habits

Response to Constructive Criticism

Homework Completion

Responsibility

Organization/Time Mgmt.

Self-Confidence

Please continue on reverse side.

Name of person completing this form

_____________________________________

Your position__________________________

School_______________________________

Phone________________________________

Email________________________________

Date completed________________________




Date of Birth___________________________________ Not

True

Somewhat

True

Certainly

True





Often loses temper





















Signature________________________________________________ Date_______________________

Parent / Teacher / Other (Please specify)______________________________________________

Thank you very much for your help © Robert Goodman, 2005



ENGLISH TEACHER REFERENCE

Full Name of Student________________________________________ Date of Birth________________ The student named above has applied to Landmark, a school for students with language-based learning disabilities. You have been chosen by the parent/guardian/student to provide

a reference for this student. Your comments will remain confidential and will not become part of the student record.Completion of this form does not sanction the student’s application to Landmark School.

How long have you known this student?________________________________________________________ Is your work with this student currently in-person, remote or hybrid?__________________________________ Frequency/class size/length:_________________________________________________________________ What is this student’s attitude towards learning and responsiveness to instruction?___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Does this student engage in appropriate social interactions with peers? Yes No Please describe _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________

Yes No Does student have difficulty paying attention to academic work or sitting through class? If yes, please describe _____________________________________________________________________________________________________________________________________________________________ Additional comments______________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________

ACADEMIC TRAITS

Go

od

Aver

age

Po

or

Academic Motivation

Study Habits


Homework Completion

Responsibility


Self-Confidence



_____________________________________

Your position__________________________

School_______________________________

Phone________________________________

Email________________________________

Date completed________________________

cbedrosianCross-Out




Date of Birth___________________________________ Not

True

Somewhat

True

Certainly

True





Often loses temper





















Signature________________________________________________ Date_______________________





Go

od

Aver

age

Po

or

Academic Motivation

Study Habits


Homework Completion

Responsibility


Self-Confidence


MATH TEACHER REFERENCE

Full Name of Student________________________________________ Date of Birth________________The student named above has applied to Landmark, a school for students with language-based learning disabilities. You have been chosen by the parent/

guardian/student to provide a reference for this student. Your comments will remain confidential and will not become part of the student record. Completion of this form does not sanction the student’s application to Landmark School.

How long have you known this student?______________________________________________________

Is your work with this student currently in-person, remote or hybrid?________________________________

Frequency/class size/length:_______________________________________________________________ What is this student’s attitude towards learning and responsiveness to instruction?______________________ _____________________________________________________________________________________ _____________________________________________________________________________________Does this student engage in appropriate social interactions with peers? Yes No Please describe _____________________________________________________________________________________ _____________________________________________________________________________________ Yes No Does student have difficulty paying attention to academic work or sitting through class? If yes, please describe ______________________________________________________________________________________Has this student been working through grade level material or a modified program? Please describe _____________________________________________________________________________________ _____________________________________________________________________________________ Additional comments____________________________________________________________________

____________________________________

Your position_________________________

School_______________________________

Phone_______________________________

Email________________________________

Date completed________________________

ACADEMIC TRAITS Name of person completing this form:




Date of Birth___________________________________ Not

True

Somewhat

True

Certainly

True





Often loses temper





















Signature________________________________________________ Date_______________________





TUTOR and/or SPECIALIST REFERENCE

Full Name of Student/Applicant____________________________________ Date of Birth____________ The student named above has applied to Landmark, a school for students with language-based learning disabilities. You have been chosen by the parent/guardian/student to provide a reference for this student. Your comments will remain confidential and will not become part of the

student record. Completion of this form does not sanction the student’s application to Landmark School.

How long have you known this student? _____________________________________________________

Is your work with this student currently in-person, remote or hybrid?_______________________________

Frequency/class size/length:______________________________________________________________

What skills are you working on with this student?

_____________________________________________________________________________________

_____________________________________________________________________________________

What is this student’s attitude towards learning and responsiveness to instruction?

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Does this student have difficulty paying attention to academic work or sitting through tutorial session?

Yes No Please describe_____________________________________________________________

_____________________________________________________________________________________

Additional comments____________________________________________________________________

_____________________________________________________________________________________

ACADEMIC TRAITS

Go

od

Aver

age

Po

or

Academic Motivation

Study Habits


Homework Completion

Responsibility


Self-Confidence



___________________________________

Your position_________________________

School_______________________________

Phone_______________________________

Email_______________________________

Date completed_______________________




Date of Birth___________________________________ Not

True

Somewhat

True

Certainly

True





Often loses temper





















Signature________________________________________________ Date_______________________





RESIDENTIAL ADVISOR REFERENCE (to be completed for applicants who are currently attending a boarding school)

Full Name of Student________________________________________ Date of Birth________________

The student named above has applied to Landmark, a school for students with language-based learning disabilities. You have been chosen by the parent/guardian/student to provide a reference for this student. Your comments will remain confidential and will not become part of the student record. Completion

of this form does not sanction the student’s application to Landmark School.

Is your work with this student currently in-person, remote or hybrid?

1. How long have you known this student?__________________________________________________

2. How does this student interact with peers?________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

3. How does this student interact with adults? ________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

4. How does this student respond to authority and constructive criticism?__________________________

____________________________________________________________________________________

____________________________________________________________________________________

5. Please describe this student’s level of independence in daily life with regard to personal hygiene, room

maintenance, and household chores.________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

ACADEMIC TRAITS

Go

od

Aver

age

Po

or

Academic Motivation

Study Habits


Homework Completion

Responsibility


Self-Confidence



_____________________________________

Your position__________________________

School_______________________________

Phone________________________________

Email________________________________

Date completed________________________




Date of Birth___________________________________ Not

True

Somewhat

True

Certainly

True





Often loses temper





















Signature________________________________________________ Date_______________________





PRIMARY CARE PHYSICIAN REPORT

(Parent/Guardian: please note that this form is required as part of your Application for Admission, but it does not replace the Physical Exam & Immunization Form that you would receive along with required

Registration Forms if your child is accepted to Landmark School.)

Part B Physician: The parent/guardian of the above-named child has applied for admission to Landmark School. We would appreciate any information about the child that you may be able to share with us. Please complete both sides of this form and return it via email, mail, or fax (see top of form). Questions? (978) 236-3000

1. Is the child in general good health? ____ Yes ____ No 2. Are immunizations up-to-date? ____ Yes ____ No 3. Is there history of any physical or mental illness in this child? ____ Yes ____ No

If yes, please be specific______________________________________________________________

_________________________________________________________________________________

4. Medication History:

Name of Medication Target Symptom(s) Current or D/C

1._____________________________ ____________________________________ __________________

2._____________________________ ____________________________________ __________________

3._____________________________ ____________________________________ __________________

4._____________________________ ____________________________________ __________________

Please attach copies of medical evaluations or pertinent records. Please complete other side of this form.

Part A Parent or Guardian: Please complete the following information in this box. Then forward this form to the Applicant’s primary care physician or pediatrician (they will complete Part B of this form).

I hereby give permission for Dr._______________________________________to release please print name of physician

medical information for my child/ward to Landmark School for Landmark’s professional use.

Full, Legal Name of Applicant/Student_________________________________Date of Birth_________

Parent/Guardian signature___________________________________________Date________________

5. Please describe any hospitalizations for this child.

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

6. Please describe any family history of learning disabilities.

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

7. Please provide any pertinent medical information about this child.

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Signature of Physician__________________________________________________

Date_______________________________________________________________

Your candid comments are greatly appreciated in helping us obtain a clear understanding of this child.



PSYCHOPHARMACOLOGIST REPORT

(NOTE: to be completed only for applicants currently being seen regarding medications)

Part A Parent or Guardian: Please complete the following information in this box. Then forward this form to the applicant’s Psychopharmacologist (they will complete Part B of this form).

I hereby give permission for Dr._______________________________________to release please print name of physician

information for my child/ward to Landmark School for Landmark’s professional use.

Full, Legal Name of Applicant/Student_________________________________Date of Birth_________

Parent/Guardian signature___________________________________________Date________________

Part B Physician: The parent/guardian of the above-named child has applied for admission to Landmark School. We would appreciate any information about the child that you may be able to share with us. Please complete both sides of this form and return it via email, mail, or fax (see top of form). Questions? (978) 236-3000

Medication History:

Name of Medication Target Symptom(s) Current or D/C

1.__________________________ ____________________________________ __________________

2.__________________________ ____________________________________ __________________

3.__________________________ ____________________________________ __________________

4.__________________________ ____________________________________ __________________

Please attach copies of medical evaluations or pertinent records.

Please complete other side of this form.

1. Has this child ever been hospitalized for psychological reasons?

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

2. Please provide any additional pertinent information about this child.

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Signature of Physician__________________________________________________

Date_______________________________________________________________

Your candid comments are greatly appreciated in helping us obtain a clear understanding of this child.



SUMMARY of COUNSELING SERVICES

(This information will remain confidential and will not become part of the student record.)

Full Name of Applicant___________________________________ Date of Birth___________________

To the Therapist: The parent/guardian of the above-named child has applied for admission to Landmark School. Your candid comments are greatly appreciated in helping us obtain a clear understanding of this child. Please complete both sides of this form (in legible print) and return it by email, mail, or fax (see above). If you have any questions or concerns, please call Landmark at 978.236.3000

Are you seeing this individual in-person or through telehealth?

1. Duration, modality, and frequency of contact

2. Presenting problem, and relevant issues addressed in treatment

3. How have this child’s learning disabilities affected your treatment of this patient?

4. History of any inpatient or residential experiences in either psychiatric or substance abuse facilities


5. Medication history – current and past

6. How would you rate your patient’s functioning in the following areas?a. Ability to separate in an age-appropriate manner

b. Ability to make and maintain friends

c. Involvement in recreational and leisure activities

d. Ability to follow rules and adjust to institutional expectations

e. Social skills

7. Current DSM-V diagnosis:

(NOTE: Please include disorder subtypes and/or specifiers as appropriate)

8. Will you remain involved in a counseling relationship with the student?

9. Would you recommend further counseling or other services that would help support this student?

Therapist Name (please print)___________________________________________ Date______________

Therapist Signature____________________________________________________________________

Phone___________________ Email______________________________________________________

Summary of Counseling -- Page 2 -- Landmark School Application

STUDENT STATEMENT

To be completed by all students (grades 1 through 12), and should be completed by the student in their own handwriting and in their own words.

Your full name__________________________________ Date completed_________________________

1. What subjects do you like best in school? Please tell us why.

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

2. What part of school do you like least? Please tell us why.

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

3. What do you do in your free time? What are your favorite activities or hobbies?

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

4. How would you like Landmark School to help you?

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________



For each item, please mark the box for Not True, Somewhat True, or Certainly True. It would help us if you answered all items as best you can even if you are not absolutely certain. Please give your answers on the basis of how things have been for you over the last six months.

Your name_________________________________________ Male / Female

Date of Birth___________________________________

Not True

Somewhat True

Certainly True

I try to be nice to other people. I care about their feelings

I am restless, I cannot stay still for long

I get a lot of headaches, stomach-aches or sickness

I usually share with others, for example CD’s, games, food

I get very angry and often lose my temper

I would rather be alone than with people of my age

I usually do as I am told

I worry a lot

I am helpful if someone is hurt, upset or feeling ill

I am constantly fidgeting or squirming

I have one good friend or more

I fight a lot. I can make other people do what I want

I am often unhappy, depressed or tearful

Other people my age generally like me

I am easily distracted, I find it difficult to concentrate

I am nervous in new situations. I easily lose confidence

I am kind to younger children

I am often accused of lying or cheating

Other children or young people pick on me or bully me

I often volunteer to help others (parents, teachers, children)

I think before I do things

I take things that are not mine from home, school or elsewhere

I get along better with adults than with people my own age

I have many fears, I am easily scared

I finish the work I’m doing. My attention is good

Your Signature_______________________________________ Today’sDate_______________________


Blank PageBlank Page

Date of Application: Applying for Grade: Current Grade: Applicants Legal Name: Country of Citizenship: Country of Birth: Primary language if other than English: Names of Stepparents: Names and ages of siblings: Organization: Diagnostic Tester: English Teacher: Math Teacher: Principal or Guidance Counselor: Tutor: Specialist: Residential Advisor: Street Address: No Please describe: OffYes_15: OffNo Please describe: OffYear of Interest: Summer of Interest: Date of Birth: Address: Date Deceased: City, State, Zip: Primary Phone: Primary Email: College: Degree: Employer: Position: Parent 1 Name: Parent 2 Name: Business Address: Check Box4: OffCheck Box7: OffCheck Box8: OffCheck Box9: OffCheck Box10: OffCheck Box11: OffCheck Box12: OffCheck Box13: OffCheck Box14: OffCheck Box15: OffCheck Box16: OffCheck Box17: OffCheck Box18: OffCheck Box19: OffCheck Box20: OffCheck Box21: OffCheck Box22: OffCheck Box23: OffCheck Box24: OffCheck Box25: OffCheck Box26: OffCheck Box27: OffReason for disciplinary action: Referral Name: Reason student is not in school: Check Box32: OffCheck Box33: OffCheck Box34: OffCheck Box35: OffCheck Box36: OffCheck Box37: OffCheck Box38: OffCheck Box39: OffCheck Box40: OffCheck Box41: OffPhysician: Physician's Phone Number: Provider: Email: Date(s): Check Box42: OffCheck Box43: OffCheck Box44: OffCheck Box45: Offfull name of applicant: Diagnostic Tester 2: Therapist/Counselor: Psychopharmacologist: Parent: strengths and interests: areas of greatest need: help your child: level of independence: additional areas of concern: name of applicant: Check Box46: OffCheck Box47: OffCheck Box48: OffCheck Box49: OffCheck Box50: OffCheck Box51: OffCheck Box52: OffCheck Box53: OffCheck Box54: OffCheck Box55: OffCheck Box56: OffCheck Box57: OffCheck Box58: OffCheck Box59: OffCheck Box60: OffCheck Box61: OffCheck Box62: OffCheck Box63: OffCheck Box64: OffCheck Box65: OffCheck Box66: OffCheck Box67: OffCheck Box68: OffCheck Box69: OffCheck Box70: OffCheck Box71: OffCheck Box72: OffCheck Box73: OffCheck Box74: OffCheck Box75: OffCheck Box76: OffCheck Box77: OffCheck Box78: OffCheck Box79: OffCheck Box80: OffCheck Box81: OffCheck Box82: OffCheck Box83: OffCheck Box84: OffCheck Box85: OffCheck Box86: OffCheck Box87: OffCheck Box88: OffCheck Box89: OffCheck Box90: OffCheck Box91: OffParent Name: Date: Check Box92: OffCheck Box93: OffCheck Box94: OffCheck Box95: OffCheck Box96: OffCheck Box97: OffCheck Box98: OffCheck Box99: OffCheck Box100: OffCheck Box101: OffCheck Box102: OffCheck Box103: OffCheck Box104: OffCheck Box105: OffCheck Box106: OffCheck Box107: OffCheck Box108: OffCheck Box109: OffCheck Box110: OffCheck Box111: OffCheck Box112: OffCheck Box113: OffCheck Box114: OffCheck Box115: OffCheck Box116: OffCheck Box117: OffCheck Box118: OffCheck Box119: OffCheck Box120: OffCheck Box121: OffCheck Box122: OffCheck Box123: OffCheck Box124: OffCheck Box125: OffCheck Box126: OffCheck Box127: OffCheck Box128: OffCheck Box129: OffCheck Box130: OffCheck Box131: OffCheck Box132: OffCheck Box133: OffCheck Box134: OffCheck Box135: OffCheck Box136: OffCheck Box137: OffCheck Box138: OffCheck Box139: OffCheck Box140: OffCheck Box141: OffCheck Box142: OffCheck Box143: OffCheck Box144: OffCheck Box145: OffCheck Box146: OffCheck Box147: OffCheck Box148: OffCheck Box149: OffCheck Box150: OffCheck Box151: OffCheck Box152: OffCheck Box153: OffCheck Box154: OffCheck Box155: OffCheck Box156: OffCheck Box157: OffCheck Box158: OffCheck Box159: OffCheck Box160: OffCheck Box161: OffCheck Box162: OffCheck Box163: OffCheck Box164: OffCheck Box165: OffCheck Box166: OffCity State Zip Code: Phone Number: Full Name of Applicant: Lenght of time: Check Box170: OffCheck Box171: OffCheck Box172: OffCheck Box173: OffCheck Box174: OffCheck Box175: OffCheck Box176: OffCheck Box177: OffCheck Box178: OffCheck Box179: OffCheck Box180: OffCheck Box181: OffCheck Box182: OffCheck Box183: OffCheck Box184: OffCheck Box185: OffCheck Box186: OffCheck Box187: OffCheck Box188: OffCheck Box189: OffCheck Box190: OffCheck Box191: OffCheck Box192: OffCheck Box193: OffCheck Box194: OffCheck Box195: OffCheck Box196: OffCheck Box197: OffCheck Box198: OffCheck Box199: OffCheck Box200: OffCheck Box201: OffCheck Box202: OffCheck Box203: OffCheck Box204: OffCheck Box205: OffCheck Box206: OffCheck Box207: OffCheck Box208: OffCheck Box209: OffCheck Box210: OffCheck Box211: OffCheck Box212: OffCheck Box213: OffCheck Box214: OffCheck Box215: OffCheck Box216: OffCheck Box217: OffCheck Box218: OffCheck Box219: OffCheck Box220: OffCheck Box221: OffCheck Box222: OffCheck Box223: OffCheck Box224: OffCheck Box225: OffCheck Box226: OffCheck Box227: OffCheck Box228: OffCheck Box229: OffCheck Box230: OffCheck Box231: OffCheck Box232: OffCheck Box233: OffCheck Box234: OffCheck Box235: OffCheck Box236: OffCheck Box237: OffCheck Box238: OffCheck Box239: OffCheck Box240: OffCheck Box241: OffCheck Box242: OffCheck Box243: OffCheck Box244: OffCheck Box245: OffCheck Box246: OffCheck Box247: OffCheck Box248: OffCheck Box249: OffCheck Box250: OffCheck Box251: OffCheck Box252: OffCheck Box253: OffCheck Box254: OffCheck Box255: OffCheck Box256: OffCheck Box257: OffCheck Box258: OffCheck Box259: OffCheck Box260: OffCheck Box261: OffCheck Box262: OffCheck Box263: OffCheck Box264: OffCheck Box265: OffYes_11: OffCheck Box266: OffCheck Box267: OffCheck Box268: OffCheck Box269: OffCheck Box270: OffCheck Box271: OffCheck Box272: OffCheck Box273: OffCheck Box274: OffCheck Box275: OffCheck Box276: OffCheck Box277: OffCheck Box278: OffCheck Box279: OffCheck Box280: OffCheck Box281: OffCheck Box282: OffCheck Box283: OffCheck Box284: OffCheck Box285: OffCheck Box286: OffName, role: Check Box288: OffCheck Box289: OffCheck Box290: OffCheck Box291: OffCheck Box292: OffCheck Box293: OffCheck Box294: OffCheck Box295: OffCheck Box296: OffCheck Box297: OffCheck Box298: OffCheck Box299: OffCheck Box300: OffCheck Box301: OffCheck Box302: OffCheck Box303: OffCheck Box304: OffCheck Box305: OffCheck Box306: OffCheck Box307: OffCheck Box308: OffCheck Box309: OffCheck Box310: OffCheck Box311: OffCheck Box312: OffCheck Box313: OffCheck Box314: OffCheck Box315: OffCheck Box316: OffCheck Box317: OffCheck Box318: OffCheck Box319: OffCheck Box320: OffCheck Box321: OffCheck Box322: OffCheck Box323: OffCheck Box324: OffCheck Box325: OffCheck Box326: OffCheck Box327: OffCheck Box328: OffCheck Box329: OffCheck Box330: OffCheck Box331: OffCheck Box332: OffCheck Box333: OffCheck Box334: OffCheck Box335: OffCheck Box336: OffCheck Box337: OffCheck Box338: OffCheck Box339: OffCheck Box340: OffCheck Box341: OffCheck Box342: OffCheck Box343: OffCheck Box344: OffCheck Box345: OffCheck Box346: OffCheck Box347: OffCheck Box348: OffCheck Box349: OffCheck Box350: OffCheck Box351: OffCheck Box352: OffCheck Box353: OffCheck Box354: OffCheck Box355: OffCheck Box356: OffCheck Box357: OffCheck Box358: OffCheck Box359: OffCheck Box360: OffCheck Box361: OffCheck Box362: OffStudent's full name: Student's name: Check Box364: OffCheck Box365: OffCheck Box366: OffCheck Box367: OffCheck Box368: OffCheck Box369: OffCheck Box370: OffCheck Box371: OffCheck Box372: OffCheck Box373: OffCheck Box374: OffCheck Box375: OffCheck Box376: OffCheck Box377: OffCheck Box378: OffCheck Box379: OffCheck Box380: OffCheck Box381: OffCheck Box382: OffCheck Box383: OffCheck Box384: OffCheck Box385: OffCheck Box386: OffCheck Box387: OffCheck Box388: OffCheck Box389: OffCheck Box390: OffCheck Box391: OffCheck Box392: OffCheck Box393: OffCheck Box394: OffCheck Box395: OffCheck Box396: OffCheck Box397: OffCheck Box398: OffCheck Box399: OffCheck Box400: OffCheck Box401: OffCheck Box402: OffCheck Box403: OffCheck Box404: OffCheck Box405: OffCheck Box406: OffCheck Box407: OffCheck Box408: OffCheck Box409: OffCheck Box410: OffCheck Box411: OffCheck Box412: OffCheck Box413: OffCheck Box414: OffCheck Box415: OffCheck Box416: OffCheck Box417: OffCheck Box418: OffCheck Box419: OffCheck Box420: OffCheck Box421: OffCheck Box422: OffCheck Box423: OffCheck Box424: OffCheck Box425: OffCheck Box426: OffCheck Box427: OffCheck Box428: OffCheck Box429: OffCheck Box430: OffCheck Box431: OffCheck Box432: OffCheck Box433: OffCheck Box434: OffCheck Box435: OffCheck Box436: OffCheck Box437: OffCheck Box438: OffCheck Box439: OffCheck Box440: OffCheck Box441: OffCheck Box442: OffCheck Box443: OffCheck Box444: OffCheck Box445: OffCheck Box446: OffCheck Box447: OffCheck Box448: OffCheck Box449: OffCheck Box450: OffCheck Box451: OffCheck Box452: OffCheck Box453: OffCheck Box454: OffCheck Box455: OffCheck Box456: OffCheck Box457: OffCheck Box458: OffCheck Box459: OffStudent's Name: Check Box461: OffCheck Box462: OffCheck Box463: OffCheck Box465: OffCheck Box466: OffCheck Box467: OffCheck Box468: OffCheck Box469: OffCheck Box470: OffCheck Box471: OffCheck Box472: OffCheck Box473: OffCheck Box474: OffCheck Box475: OffCheck Box476: OffCheck Box477: OffCheck Box478: OffCheck Box479: OffCheck Box480: OffCheck Box481: OffCheck Box482: OffCheck Box484: OffCheck Box485: OffCheck Box486: OffCheck Box487: OffCheck Box488: OffCheck Box489: OffCheck Box490: OffCheck Box491: OffCheck Box492: OffCheck Box493: OffCheck Box494: OffCheck Box495: OffCheck Box496: OffCheck Box497: OffCheck Box498: OffCheck Box499: OffCheck Box500: OffCheck Box501: OffCheck Box502: OffCheck Box503: OffCheck Box504: OffCheck Box505: OffCheck Box506: OffCheck Box507: OffCheck Box508: OffCheck Box509: OffCheck Box510: OffCheck Box511: OffCheck Box512: OffCheck Box513: OffCheck Box514: OffCheck Box515: OffCheck Box516: OffCheck Box517: OffCheck Box518: OffCheck Box519: OffCheck Box520: OffCheck Box521: OffCheck Box522: OffCheck Box523: OffCheck Box524: OffCheck Box525: OffCheck Box526: OffCheck Box527: OffCheck Box528: OffCheck Box529: OffCheck Box530: OffCheck Box531: OffCheck Box532: OffCheck Box533: OffCheck Box534: OffCheck Box535: OffCheck Box536: OffCheck Box537: OffCheck Box538: OffCheck Box539: OffCheck Box540: OffCheck Box541: OffCheck Box542: OffCheck Box543: OffCheck Box544: OffCheck Box545: OffCheck Box546: OffCheck Box547: OffCheck Box548: OffCheck Box549: OffCheck Box550: OffCheck Box551: OffCheck Box552: OffCheck Box553: OffCheck Box554: OffCheck Box555: OffCheck Box556: OffCheck Box557: OffCheck Box558: OffName, Role: Check Box559: OffCheck Box560: OffCheck Box561: OffCheck Box562: OffCheck Box563: OffCheck Box564: OffCheck Box565: OffCheck Box566: OffCheck Box567: OffCheck Box568: OffCheck Box569: OffCheck Box570: OffCheck Box571: OffCheck Box572: OffCheck Box573: OffCheck Box574: OffCheck Box575: OffCheck Box576: OffCheck Box577: OffCheck Box578: OffCheck Box579: OffCheck Box581: OffCheck Box582: OffCheck Box583: OffCheck Box584: OffCheck Box585: OffCheck Box586: OffCheck Box587: OffCheck Box588: OffCheck Box589: OffCheck Box590: OffCheck Box591: OffCheck Box592: OffCheck Box593: OffCheck Box594: OffCheck Box595: OffCheck Box596: OffCheck Box597: OffCheck Box598: OffCheck Box599: OffCheck Box600: OffCheck Box601: OffCheck Box602: OffCheck Box603: OffCheck Box604: OffCheck Box605: OffCheck Box606: OffCheck Box607: OffCheck Box608: OffCheck Box609: OffCheck Box610: OffCheck Box611: OffCheck Box612: OffCheck Box613: OffCheck Box614: OffCheck Box615: OffCheck Box616: OffCheck Box617: OffCheck Box618: OffCheck Box619: OffCheck Box620: OffCheck Box621: OffCheck Box622: OffCheck Box623: OffCheck Box624: OffCheck Box625: OffCheck Box626: OffCheck Box627: OffCheck Box628: OffCheck Box629: OffCheck Box630: OffCheck Box631: OffCheck Box632: OffCheck Box633: OffCheck Box634: OffCheck Box635: OffCheck Box636: OffCheck Box637: OffCheck Box638: OffCheck Box639: OffCheck Box640: OffCheck Box641: OffCheck Box642: OffCheck Box643: OffCheck Box644: OffCheck Box645: OffCheck Box646: OffCheck Box647: OffCheck Box648: OffCheck Box649: OffCheck Box650: OffCheck Box651: OffCheck Box652: OffCheck Box653: OffCheck Box654: OffCheck Box655: OffFull Name of Student: pertinent medical information: Yes: No: If yes, please be specific: Medication 1: Medication 2: Medication 3: Medication 4: hospitalized for psychological reasons?: any additional pertinent information: Name of Applicant: Duration, modality, and frequency?: Presenting problem?: Impact of learning disabilities on treatment?: Inpatient or residential experiences?: Medical history: Ability to seperate: Make and maintain friends: Recreational and leisture activites: Follow rules: Social skills: Continued counseling relationship: DSM-V diagnosis: Further counseling?: Therapist Name: Age: Ethnicity: Gender: School K: Target Symptoms 1: Target Symptoms 2: Target Symptoms 3: Target Symptoms 4: Current or DC 1: Current or DC 2: Current or DC 3: Current or DC 4: English Teacher Phone: Tester 1 Email: Tester 1 Phone: Tester 2 Email: Tester 2 Phone: English Teacher Email: Math Teacher Phone: Math Teacher Email: Tutor Phone: Tutor Email: Specialist Phone: Specialist Email: Principal or Guidance Counselor Email: Advisor Phone: Residential Advisor Email: Psycopharmacologist Email: Prin: or GC Phone:

Diagnoses; By whom; When: Medical Condition(s): Reason(s): P2 Preferred Name: P2 Relationship: P2 Date of Birth: P2 Date Deseased: Relationship: Preferred Name: P2 Address: P2 City, State, Zip: P2 Primary Phone: P2 Primary Email: P2 College: P2 Degree: P2 Employer: P2 Position: P2 Business Address: Preferred: P1 Date of Birth: Check Box5: OffCheck Box6: Offdate_: _Date: Date__: __Date: Date___: Date -: - Date: Check Box667: OffCheck Box668: OffCheck Box669: OffCheck Box670: OffCheck Box671: OffCheck Box672: OffCheck Box673: OffCheck Box674: OffCheck Box675: OffCheck Box676: OffCheck Box677: OffCheck Box678: OffCheck Box680: OffCheck Box681: OffCheck Box682: OffCheck Box683: OffCheck Box684: OffCheck Box685: OffCheck Box686: OffCheck Box687: OffCheck Box688: OffCheck Box689: OffCheck Box690: OffCheck Box691: OffCheck Box692: OffCheck Box693: OffCheck Box694: OffCheck Box695: OffCheck Box696: OffCheck Box697: OffCheck Box698: OffCheck Box699: OffCheck Box700: OffCheck Box701: OffCheck Box702: OffCheck Box703: OffLength of time?: _length of time: Length of time_: _ Length of time: Is this student a positive and productive member of the school community?: Does this student engage in appropriate social interactions with peers and teachers?: If yes to problems with discipline or suspension, please describe: Legal guardian(s): With whom does the applicant reside?: K year: School 1st grade: 1st grade year: School 2nd grade: 2nd grade year: 3rd grade year: School 3rd grade: 4th grade year: School 4th grade: 5th grade year: School 5th grade: 6th grade year: School 6th grade: 7th grade year: School 7th grade: 8th grade year: School 8th grade: 9th grade year: School 9th grade: 10th grade year: School 10th grade: 11th grade year: School 11th grade: 12th grade year: School 12th grade: Referral's Address: Referral's Postion: Referral's Phone: Referral's Email: Medication(s), Start date, Prescribing Physician, Condition: Parent Signature: Additional comments from Principal or School Guidance Counselor: Psychopharmacologist Phone: Parent or Guardian Signature (typed): Name of person completing P/SGC Reference: Position for P/SGC Reference: School for P/SGS Reference: Phone for P/SGC Reference: Email for P/SGC Reference: Signature for P/SGC Reference: Student name: in-person, remote or hybrid?: attitude towards learning?: social interactions with peers?: level of attention?: Additional comments from English reference: Name of English Reference: Position for English Reference: School of English Reference: Phone for English Reference: Email for English Reference: Signature for English Reference: currently in person, remote or hybrid?: Frequency, class size, length: frequency/ class size/ length: attidude towards learning and responsiveness?: appropriate social interactions with peers?: difficulty paying attention?: grade level material or modified program?: additional comments from math teacher: Name of math reference: Position of math reference: School of math reference: math reference phone number: math reference email: Math Reference Signature (typed): Math Reference Name, Role: Work is in-person, remote or hybrid?: frequency /class size /length: What skills are you working on with this student?: What is this student's attitude towards learning and responsiveness to instruction?: if difficulty, please describe: Additional comments from tutor/ specialist: Name of tutor/specialist: Position of tutor/specialist: School, tutor/specialist: tutor/specialist phone: tutor/specialist email: Tutor/Specialist Name, Role: Signature of Tutor/Specialist (typed): How does this student interact with peers?: How does this student interact with adults?: How does this student respond to authority and constructive criticism?: Please describe this student's level of indepence in daily life?: Residential Advisor Reference Name: Residential Advisor Reference Position: Residential Advisor Reference School: Residential Advisor Reference Phone: Residential Advisor Reference Email: Residential Advisor's Name, Role: Signature of Residential Advisor (typed): Name of Primary Care Physician: Please describe any family history of learning disabilities: Please describe any hospitalizations for this child: Signature of Physician (typed): Name of Pharacologist: Parent signature: medication 1: medication 2: medication 3: medication 4: target symptoms 1: target symptoms 2: target symptoms 3: target symptoms 4: current or DC 1: current or DC 2: current or DC 3: current or DC 4: Signature of Psychpharmacologist: Therapist Signature, typed: Therapist Phone: Therapist Email: Check Box1: OffCheck Box2: OffCheck Box3: OffCheck Box167: OffCheck Box168: OffCheck Box169: OffCheck Box287: OffCheck Box363: OffCheck Box460: OffCheck Box464: OffCheck Box483: OffCheck Box580: OffCheck Box656: OffCheck Box657: OffCheck Box28: OffCheck Box29: OffCheck Box30: OffCheck Box31: Off

Documents

Landmark School · 2020. 10. 30. · Landmark School, Office of Admission, 429 Hale Street, PO Box 227, Prides Crossing, MA 01965-0227. Diagnostic Testing Requirements In order to