GOVT.

SECONDARY SCHOOL FOR HEARING IMPAIRED GIRLS, SARGODHA

DHH CHILD ADMISSION SCREENING FORM

Student Information:
- Name:__________________________- Date of Birth:________________________- Gender:________
- Grade Applying for:_________________- Current School (if applicable):_________________________

Parent/Guardian Information:
- Parent/Guardian Name(s):_________________________- Contact Information:__________________
- Preferred Mode of Communication (e.g., sign language, spoken language):______________________

Hearing Assessment:
- Date of Most Recent Hearing Assessment:____________ - Degree of Hearing Loss:_______________
- Type of Hearing Loss:_____________________________ - Hearing Devices (if any):_______________
- Audiologist's Recommendations:________________________________________________________

Communication Modality:
- Primary Mode of Communication:___________________- Proficiency Level in Chosen Mode:_______
- Secondary Mode of Communication:_________________- Proficiency Level in Secondary Mode:_____

Educational History:
- Previous School(s):____________________________________________________________________
- Special Education Services Received:_________________- Accommodations Provided (if any):_______
- Current or Past Individualized Education Plan (IEP) Information:________________________________

Language and Communication Skills:

- Expressive Language Skills:________________________- Receptive Language Skills:_______________
- Ability to Communicate with Peers and Adults:_____________________________________________
- Any Notable Communication Challenges or Strengths:_______________________________________

Social-Emotional Development:
- Social Interaction Observations:
Initiating and maintaining eye contact.
Engaging in turn-taking during conversations or activities
Responding to verbal and non-verbal cues from peers and adults.
Demonstrating active listening skills.
Demonstrating appropriate body language and gestures.
Engaging in cooperative play or group activities.
Demonstrating empathy and understanding of others' emotions.

- Emotional Regulation Observations:

Recognizing and labeling emotions (e.g., happy, sad, angry).
Demonstrating self-awareness of emotional states.
Using appropriate coping strategies when faced with challenging situations.

Ms. SABIRA SHAKIR (M.Phil. Clinical Psychology)

GOVT. SECONDARY SCHOOL FOR HEARING IMPAIRED GIRLS, SARGODHA

Managing frustration or disappointment effectively as per age.

Demonstrating self-control and regulation of emotional reactions.
Seeking support or assistance when needed.
Demonstrating resilience in the face of setbacks.
Displaying age-appropriate emotional expression and regulation.
- Any Notable Social-Emotional Concerns or Strengths:_______________________________________

Cognitive Abilities:
Orientation: [e.g., Oriented to time, place, and person]
Memory: [e.g., Immediate, short-term, long-term memory]
Attention and Concentration: [e.g., Able to focus, distractible]
Abstract Thinking: [e.g., Able to understand abstract concepts]
Insight: [e.g., Awareness of current situation and condition]
- Cognitive Assessment Results (if available):________________________________________________
- Identified Intellectual Strengths or Weaknesses:____________________________________________

Adaptive Behavior:
- Daily Living Skills (e.g., self-care, independence):____________________________________________
- Adaptability in Different Environments:___________________________________________________

Speech and Language Evaluation:

- Speech Intelligibility:________________________- Language Assessment Results:_________________
- Identified Speech or Language Disorders (if any):____________________________________________

Psychological:
- Identified Emotional or Behavioral Concerns (if any):_________________________________________

Family Input:
- Parent/Guardian's Perspective on Child's Development and Needs:_____________________________

Health Assessment:
- Relevant Health Conditions:______________________- Health-Related Accommodations or
Considerations:________________________________________________________________________

Educational Goals:
- Expectations of Parents/Guardians about child education:____________________________________

Support Services:
- Identify Necessary Support Services, Accommodations, and Interventions:_______________________

School Psychologist's Signature: Parent/Guardian's Signature:

- Date: - Date:

Ms. SABIRA SHAKIR (M.Phil. Clinical Psychology)