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Traumatic Brain Injury
Other Health Impairment
Specific Learning Disability
Speech or Language Impairment
Visual Impairment (Including Blindness)
Hearing Impairment (Including Deafness)
Other (Please list below)
(Favorite activities, topics of interest, school program, community program, in school and/or private therapies, etc.)
(Reads, uses written notes to assist with auditory understanding, write, uses picture schedule or written schedule, etc.)
Contribution to a Large Group
Staying on Track with Task
Listening to Other's Opinions
Other (Please describe below)
(Aggression towards classmates/adults, leaving areas without permissions, tantrums, fighting, verbal abuse, refusing to complete work, etc.)
Stay on Topic of Other's Interests
Ask for More Information
Discuss Topics of Own Interest
Make Comments About What Others Say
Behavior Intervention Plan (Please email to email@example.com)
Behavior Services (Please describe below)
(What happens, what makes the situation worse, what helps most?)
Drop off will be TBD.