Supplemental Emotional indicators Record/Form
Section 1. Identifying Information
Name Motor impairment Yes No C1
Female] Male Grade —____ Type
Yea Month Day——_Langunge Spoken
Date Tested eee ay ay SS Scoot
Date of ith pa as Se Hn Beer Nee,
Age ——— — —_ aariners tte
Section 2. Observational Notes and Interpretation
Observational Notes
Preliminary Interpretive Surnmary
Benes restate Hogho fin Canpany anid th pemsson
orl cones hs form 25] may ephedra
£1007 ROD Fe "ODA Sha ie Ast TAH
Trsas 67690 Wo wo B70 Fa 163 poneSection 3. Scoring of Presence or Absence of the Koppitz Emotional Indicators
{See Chapter7of the KOPPIZ-2 Examines Manual fr detaled criteria scoring examples)
Scoring Criteria
1. Confused Order
Designs are scattered arbitrary on paper thou logical sequence or order. Confused orders not scored
inthe presence of any sort of ede or logical sequence. This may include arrangements fom top of page