Psychoeducational assessment

School:

Student’s name:

I. Personal Information

Date and place of birth:

Address:

Phone no.:

Parents’ name: Father______________________ Mother____________________

Parents’ profession and workplace:

Father profession: ________________workplace:_____________________

Mother profession: _______________workplace: ___________________

Siblings:

II. Information about the family environment:

Harmony Conflicts Disorganized family

Family financial situation:

Very good good average poor

III. Significant medical information:

Normal physical development:

Diseases:

Deficiencies, handicaps:
 IV. Information related to school performances

1. Educational situation

Class Annual Subjects with results Subject

average Weaker Stronger failures

2. Outstanding results/success/competitions:

3. Class behaviour: pays attention receptive participates

Other:

4. Preparing for the lessons:

Regularly own effort no initiative no homework

5. Explanations for success/failures:

V. Social integration of the student

1. Behaviour in the family:
a. Parents
b. Siblings
c. Participation in family activities
2. Behaviour at school:
a. Teachers:
b. Classmates:
 VI. Characterization

Level of development
Weak Medium Good Very Exceptional
good
1 Learning
results
2 IQ level
3 Attention
4 Memory
5 Language use
6 Emotional
balance
7 Open-
mindedness
8 Rhythm of
activities
9 Diligence
10 Self-
confidence
11 Independenc
e

General comments:

Recommendations:

Class master: