exhibit d. sample letter to parents about

Exhibit D. Sample Letter to Parents about Neuropsychological Assessment

{Insert Letterhead}

LETTER TO PARENTS REGARDING NEUROPSYCHOLOGICAL ASSESSMENT

Dear {insert parent or guardian name} ,

Following our recent telephone conversation, this is to confirm {insert child’s name} ’s

neuropsychological assessment on {insert date and time} , at the request of {insert

attorney or other retaining party} . Please plan to be at our office for approximately 7 hours

on your appointment day. As we discussed, we may need to see {insert child’s name} for an

additional session if further testing is required.

{insert child’s name} may be curious about the assessment. Please let your child know that this

is not a typical doctor’s visit (e.g. there are no needles or medical examinations). Your child will

be asked to participate in activities that help us understand more about thinking, learning, and

remembering abilities. Your child may be asked to assemble puzzles, draw pictures, solve

problems, and similar activities.

We are located at {insert address} . Parking is located at {insert parking details}

. See attached map for office location.

On the day of your appointment, please bring copies of the following that we may keep:

1. Your child’s most recent school report card and year-end report cards for previous years.

2. Your child’s Individualized Education Plan (IEP) or other relevant school documents, if

your child has these.

3. Glasses or hearing aids if your child needs them.

4. A lunch and/or snack for yourself and your child.

Enclosed are questionnaires to be completed by {insert child’s name} ’s classroom teacher.

Please sign and complete the enclosed Consent Form for Release of School Information (see

Exhibit F, this volume) and give it and the questionnaires to the teacher along with the self-

addressed stamped envelope.

We look forward to meeting with you and {insert child’s name} . Please contact us or your

attorney should you have any further questions regarding this assessment.

Sincerely,

Exhibit E. Sample Letter to Teacher about Neuropsychological Assessment

{Insert Letterhead}

LETTER TO TEACHER REGARDING NEUROPSYCHOLOGICAL ASSESSMENT

Re: {insert child’s name}

Dear Teacher,

We have scheduled a neuropsychological assessment with your student {insert child’s name}

, as part of a neuropsychological evaluation for legal purposes requested by {insert

attorney or retaining party} , and with the consent of your student’s parents or guardian. To

help us with our assessment, could you kindly complete the enclosed forms and return them to us

as soon as possible. Your observations of {insert child’s name} will form an important part of

this assessment and we appreciate the time and effort you spend on completing these

questionnaires. Please find enclosed a Consent for Release of Information which has been signed

by the parent or guardian, and which is intended for your school’s records. The following items

are enclosed:

Consent Form for Release of School Information (see Exhibit F, this volume), signed by

the parent or guardian and to be retained by the school for your records

{insert list of questionnaires enclosed}

Thank you for your assistance in our assessment. Please do not hesitate to contact me at {insert

contact information} should you have any questions.

Sincerely,

Exhibit F. Sample Consent Form for Release of Information from School

{Insert Letterhead}

CONSENT FORM FOR RELEASE OF SCHOOL INFORMATION

I hereby authorize {insert name of school and school board}

to release any or all educational data, including information labelled “confidential” (e.g.,

achievement test results, psychoeducational assessments, speech and language reports, including

raw test data) to Dr. Smith regarding:

________________________________

Name of Child/Adolescent

___________________________________

Date

___________________________________

Signature of Parent/Guardian

___________________________________

Signature of Child (when appropriate)

___________________________________

Signature of Witness

NOTE:

This form is to be signed by the parent and

retained by the school

Exhibit G. Checklist for a Pediatric Independent Neuropsychological Evaluation Interview

CHECKLIST FOR A PEDIATRIC INDEPENDENT

NEUROPSYCHOLOGICAL EVALUATION INTERVIEW

GENERAL

Purpose and overview of evaluation

Consent procedures

PRE-INJURY

Birth and early development

School achievement and school placements prior to injury (grade by grade)

General medical health, physical functioning, childhood illnesses

Other head injuries or accidents

Specific queries re: definite or suspected history or signs of ADHD, behaviour problems

or learning difficulties

INJURY DETAILS

Details of injury (including LOC, PTA, length of retrograde amnesia, post-injury medical

complications, pain, medications, hospitalizations)

Chronology of post-injury symptoms (onset, course, resolution)

POST-INJURY COURSE

Course of recovery (improvement, plateauing, worsening)

Cognitive functioning

Physical functioning

School functioning

Emotional and behavioural functioning (with specific queries re: PTSD, anxiety,

depression, friendships/social interactions; in older adolescents, sexual activity and

substance use)

Results of prior evaluations

Results of prior interventions

Extra-curricular activities and career goals

Expectations for outcome

FAMILY HISTORY

Parental occupation, education, family background

Family medical history – query ADHD, learning disorders, psychiatric (bipolar,

depression), chronic pain; problems with the law; substance abuse

Family coping and family conflict

CHILD INTERVIEW

Understanding of the evaluation

Understanding of the accident

Course of recovery (improvement, plateauing, worsening)

Physical functioning

Cognitive functioning

School functioning

Emotional and behavioural functioning

Query PTSD, anxiety, depression (in older adolescents, sexual activity and substance use)

Social functioning

Home situation, relationship with parents, teachers

Extra-curricular activities

Career goals

Expectations for outcome

Exhibit H. Sample Traumatic Brain Injury Interview Form

TRAUMATIC BRAIN INJURY INTERVIEW: EXAMINEE AND/OR COLLATERAL

INFORMANT’S DESCRIPTION OF ACCIDENT/INJURY

Name: ________________________ Date: _______________ Interviewer: _____________

Date of Accident: _________________________ Time of Accident: ____________________

Place of Accident: ______________________________________________________________

OVERVIEW OF THE ACCIDENT/INJURY

Last memory prior to accident _____________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Memory of accident itself _________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Loss of consciousness (onset, length, resolution) _______________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

First memories after accident ______________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Post-traumatic amnesia (onset, length, resolution) ______________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

SYMPTOMS AND COURSE OVER TIME

Dizziness ______________________________________________________________________

______________________________________________________________________________

Vertigo _______________________________________________________________________

______________________________________________________________________________

Diplopia_______________________________________________________________________

______________________________________________________________________________

Headache ______________________________________________________________________

______________________________________________________________________________

Nausea ________________________________________________________________________

______________________________________________________________________________

Tinnitus _______________________________________________________________________

______________________________________________________________________________

Other _________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

POST-TRAUMATIC STRESS SYMPTOMS

Flashbacks _____________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Nightmares ____________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Fear/anxiety/avoidance ___________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

FUNCTIONAL IMPACT OF ACCIDENT/INJURY

Perceived impact on school functioning ______________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Perceived impact on emotional and behavioral functioning _______________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Perceived impact on activities of daily living and functional independence __________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Perceived impact on social and recreational activities ___________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Perceived impact on activities of daily living __________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Exhibit I. Sample Background and History Questionnaire

Dear Parents/Guardian: The following is a detailed questionnaire on your child’s development, medical

history, and current functioning at home and at school. This information will be integrated with the

testing results in order to provide a better picture of your child’s abilities as well as any problem areas.

Please fill out this questionnaire as completely as you can.

CHILD’S FAMILY

Child’s Name: _______________________________________________ Today’s Date: ______________

Birthdate: ____________ Age: _____ Grade: _____ Name of School: _________________________

Birth Country: ______________________________ Age on arrival in Canada if born elsewhere: _______

Person filing out this ___________

City of residence: _________________ Home phone #: ______________ Work phone #: ____________

Biological Mother’s Name: ________________________ Age: _____ Highest Grade Completed: _____

Number of Years of Education: ________ Degree/Diploma (if applicable): _________________________

Occupation: _____________________________________________________________________________

Biological Father’s Name: ________________________ Age: _____ Highest Grade Completed: ______

Number of Years of Education: _______ Degree/Diploma (if applicable): __________________________

Occupation: _____________________________________________________________________________

Marital status of biological parents: ___

If biological parents are separated or divorced:

How old was this child when the separation occurred? __________

_____________________________________________________________________________________

Stepparent’s Name: ______________________ Age: _____ Occupation: ______________________

If this child is not living with either biological parent:

Reason: ______________________________________________________________________________

______

Name(s) of legal guardian(s): ____________________________________________________________

List all people currently living in your child’s household:

Name Relationship to Child Age

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

If any brothers or sisters are living outside the home, list their names and ages:

_______________________________________________________________________________________

_______________________________________________________________________________________

Primary language spoken in the home: ________________________________________________________

Other languages spoken in the home: _________________________________________________________

If your child’s first language is not English, please complete the following:

Child’s first language: ___________________________________ Age at which your child learned

English: ______________________________________________________________________________

BEHAVIOUR CHECKLIST (CURRENT)

Place a check mark () next to behaviours that you believe your child currently exhibits to an excessive

or exaggerated degree when compared to other children his or her age.

Sleeping and Eating

Nightmares

Sleepwalking

Trouble sleeping (describe):

_______________________________________

_______________________________________

_______________________________________

Eats poorly

Picky eater

Eats excessively

Social Development

Prefers to be alone

Shy or timid

More interested in objects than in people

Difficulty making friends

Plays or socialises with younger children

Teased by other children

Bullies other children

Does not seek friendships with peers

Not sought our for friendship by peers

Does not play or socialise with other children

outside of school

Difficulty seeing another person’s point of view

Doesn’t empathise with others

Overly trusting of others

Easily taken advantage of

Overly familiar with people

Doesn’t appreciate humour

Overly attached to certain people

Behaviour

Stubborn

Irritable

Frequent tantrums

Strikes out at others

Throws things at others

Destroys things

Angry or resentful

Oppositional

Negativistic

Lying

Argues with adults

Low frustration threshold

Blames others for own mistakes

Daredevil behaviour

Runs away

Needs a lot of supervision

Impulsive (does things without thinking)

Talks excessively

Skips school

Interrupts frequently

Purposely harms or injures self

Dangerous to self or others (e.g., running into

street) describe:

_______________________________________

_______________________________________

_______________________________________

Talks about killing self (describe):

_______________________________________

_______________________________________

_______________________________________

Unusual fears, habits or mannerisms (describe):

_______________________________________

_______________________________________

_______________________________________

Steals

Depressed

Cries frequently

Excessively worried and anxious

Overly preoccupied with details

Overly attached to certain objects

Not affected by praise

Not affected by negative consequences

Drug abuse

Alcohol abuse

Sexually active

Other Problems

Wets bed

Wets self during the day

Poor bowel control (soils self)

Motor/Vocal tics

Overreacts to noises

Overreacts to touch

Fails to react to loud noise

Poor sense of danger

Has blank spells

Sloppy table manners

Bangs head

Bites nails

Picks nose

Sucks thumb

Masturbation in public places

Excessive daydreaming and fantasy life

Motor Skills

Poor fine motor coordination

Poor gross motor coordination

Clumsy

Cannot tie shoes

Cannot dress self

Difficulty walking

Difficulty running

Cannot throw or catch

BEHAVIOUR CHECKLIST (IF YOUR CHILD IS BEING ASSESSED DUE TO AN INJURY OR ACCIDENT, PLEASE

COMPLETE WITH REGARD TO PRE-INJURY FUNCTIONING)

Place a check mark () next to behaviours that you believe your child exhibited to an excessive or

exaggerated degree, prior to his or her injury, when compared to other children his or her age.

Sleeping and Eating

Nightmares

Sleepwalking

Trouble sleeping (describe):

_______________________________________

_______________________________________

_______________________________________

Eats poorly

Picky eater

Eats excessively

Social Development

Prefers to be alone

Shy or timid

More interested in objects than in people

Difficulty making friends

Plays or socialises with younger children



Does not seek friendships with peers

Not sought our for friendship by peers

Does not play or socialise with other children

outside of school

Difficulty seeing another person’s point of view

Doesn’t empathise with others

Overly trusting of others

Easily taken advantage of

Overly familiar with people

Doesn’t appreciate humour

Overly attached to certain people

Behaviour

Stubborn

Irritable

Frequent tantrums

Strikes out at others

Throws things at others

Destroys things

Angry or resentful

Oppositional

Negativistic

Lying

Argues with adults

Low frustration threshold

Blames others for own mistakes

Daredevil behaviour

Runs away

Needs a lot of supervision

Impulsive (does things without thinking)

Talks excessively

Skips school

Interrupts frequently

Purposely harms or injures self

Dangerous to self or others (e.g., running into

street) describe:

_______________________________________

_______________________________________

_______________________________________

Talks about killing self (describe):

_______________________________________

_______________________________________

_______________________________________

Unusual fears, habits or mannerisms (describe):

_______________________________________

_______________________________________

_______________________________________

Steals

Depressed

Cries frequently

Excessively worried and anxious

Overly preoccupied with details

Overly attached to certain objects

Not affected by praise

Not affected by negative consequences

Drug abuse

Alcohol abuse

Sexually active

Other Problems

Wets bed

Wets self during the day

Poor bowel control (soils self)

Motor/Vocal tics

Overreacts to noises

Overreacts to touch

Fails to react to loud noise

Poor sense of danger

Has blank spells

Sloppy table manners

Bangs head

Bites nails

Picks nose

Sucks thumb

Masturbation in public places

Excessive daydreaming and fantasy life

Motor Skills

Poor fine motor coordination

Poor gross motor coordination

Clumsy

Cannot tie shoes

Cannot dress self

Difficulty walking

Difficulty running

Cannot throw or catch

EDUCATION PROGRAM

Does your child have an individual education plan (IE

If yes, when was the IEP created? ____________________

If not satisfied, please explain: __________________________________________________________________

__________________________________________________________________________________________

If yes, what grade(s) and why? _________________________________________________________________

__________________________________________________________________________________________

Is your child’s curricu

If yes, please describe: ________________________________________________________________________

__________________________________________________________________________________________


__________________________________________________________________________________________


__________________________________________________________________________________________

Has your chi


__________________________________________________________________________________________


__________________________________________________________________________________________

Rate your child’s academic performance relative to other children of the same age. Please estimate the grade level

your child is functioning at in the given area if he or she is above or below average.

Above Average Average Below Average Impaired Grade Level

Handwriting _____

Spelling _____

Punctuation _____

Vocabulary _____

Grammar _____

Reading speed _____

Reading comprehension _____

Math skills _____

Check any problems reported from school:

Difficulty sustaining attention

Easily distracted

Daydreaming

Fidgeting / restless

Frequently gets out of seat

Difficulty working quietly

Difficulty working independently

Doesn’t want to be called on

Blurts out answers

Difficulty following instructions

Doesn’t cooperate well in group activities

Doesn’t respect the rights of others

Shifts from one activity to another

Does better in a one-to-one relationship

Won’t wait his/her turn


Talking back

Refusing to do work


Fighting

Messy / disorganised

Does not like school

Truant

Excessively tired or sleepy

Describe briefly other classroom or school problems if applicable:

COGNITIVE SKILLS

Rate your child’s cognitive skills relative to other children of the same age.

Above Average Average Below Average Impaired

Speech

Comprehension of speech

Problem solving

Attention span

Memory for events

Organisational skills

Memory for facts

Learning from experience

Conceptual thinking

Overall Intelligence

Check any specific problems:

Poor articulation

Difficulty finding words to express self

Disorganised speech

Ungrammatical speech

Talks like a younger child

Slow learner

Forgets to do things

Easily distracted

Frequently forgets instructions

Frequently loses belongings

Difficulty planning tasks

Doesn’t foresee consequences of actions

Slow thinking

Describe briefly any other cognitive problems that your child may have: _________________________

___________________________________________________________________________________

___________________________________________________________________________________

Describe any special skills or abilities that your child may have: ________________________________

___________________________________________________________________________________

___________________________________________________________________________________

DEVELOPMENTAL HISTORY

If your child is adopted, please fill in as much of the following information as you are aware of.

During pregnancy, did the mother of this child:

If yes, what kind? ____________________________________________________________________________

If yes, how many cigarettes each day? ____________________________________________________________

If yes, what kind? ____________________________________________________________________________

Approximately how much alcohol was consumed each day? __________________________________________

Use dr

If yes, what kind? ____________________________________________________________________________

How often were drugs used? ___________________________________________________________________

List any complications during pregnancy (excessive vomiting, excessive staining/blood loss, threatened

miscarriage, infections, toxemia, fainting, dizziness, etc.): ____________________________________________

__________________________________________________________________________________________

Duration of pregnancy (weeks): __________ Duration of labour (hours): __________ Apgars: _____ / _____

If yes on any of other above, for what reason? _____________________________________________________

__________________________________________________________________________________________

If yes on any of other above, for what reason? _____________________________________________________

__________________________________________________________________________________________

What was your child’s birth weight? _____


__________________________________________________________________________________________

__________________________________________________________________________________________

Were there


__________________________________________________________________________________________

Was there any maternal depression during the immediate post-natal period?


__________________________________________________________________________________________


__________________________________________________________________________________________


__________________________________________________________________________________________


__________________________________________________________________________________________

Were any of the following present (to a significant degree) during infancy or the first few years of life?

Unusually quiet or inactive

Did not like to be held or

cuddled

Not alert

Difficult to soothe

Colic

Excessive restlessness

Excessive sleep

Diminished sleep

Headbanging

Constantly into everything

Excessive number of accidents

compared to other children

Please indicate the approximate age in months or years at which your child showed the following behaviours. If

you feel that you child was early or late in showing a listed behaviour, please indicate by checking the appropriate

box. Check never if your child has never shown the listed behaviour.

Age Early Late Never Age Early Late Never

Smiled ________ Tied shoelaces ________

Rolled over ________ Dressed self ________

Sat alone ________ Fed self ________

Crawled ________ Bladder trained, day ________

Walked ________ Bladder trained, night ________

Ran ________ Bowel trained ________

Babbled ________ Rode tricycle ________

First word ________ Rode bicycle ________

Sentences ________

CURRENT MEDICATIONS

List all medications that your child is currently taking:

Medication Reason Taken Dosage (If known) Start Date

MEDICAL HISTORY

Date of last physical examination:

Date of last vision examination:

Date of last hearing examination:

Place a check next to any illness or condition that your child has had. When you check an item, also note

the approximate date of the illness (if you prefer, you can simply indicate the child’s age at illness).

Illness or condition Date(s)/age(s) Illness or condition Date(s)/age(s)

s

FAMILY MEDICAL HISTORY

Place a check next to any illness or condition that any member of the immediate family (i.e., brothers,

sisters, aunts, uncles, cousins, grandparents) has had. Please note the family member’s relationship to the

child.

Condition Relationship to

child

Condition Relationship to

child

Seizures or Epilepsy _____________ Neurological illness or disease _____________

Attention deficit _____________ Mental illness _____________

Hyperactivity _____________ Depression or anxiety _____________

Learning disabilities _____________ Tics or Tourette’s syndrome _____________

Mental retardation _____________ Alcohol or drug abuse _____________

Childhood behaviour problems _____________ Suicide attempt _____________

If yes, please list prescription or describe (e.g., nearsighted): _____________________________________

If yes, please describe): ___________________________________________________________________

Does your

List had any previous assessments that your child has had:

Dates of Testing Name of Examiner

Psychiatric

Psychological

Neuropsychological

Educational

Speech Pathology

Have there been any recent stressors that you think may be contributing to your child’s difficulties (e.g.,

illness, deaths, operations, accidents, separations, divorce of parents, parent changed job, changed schools,

family moved, family financial problems, remarriage, sexual trauma, other losses)? __________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

List any form of psychological/psychiatric treatment that your child has had (e.g., psychotherapy, family

therapy, inpatient or residential treatment):

Type of Treatment Dates Name of Therapist

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

OTHER INFORMATION

What are your child’s favourite activities? __________________________________________________

____________________________________________________________________________________

List any special interests that your child has: ________________________________________________

____________________________________________________________________________________

List any sports your child plays: __________________________________________________________

If yes, please describe briefly: ____________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

What disciplinary techniques do you usually use when your child behaves inappropriately? Place a check

next to each technique that you usually use.

Ignore problem behaviour

Scold child

Take away some activity or food

Threaten child

Reason with child

Redirect child’s interest

Don’t use any technique

Tell child to sit on chair

Send child to his/her room

Spank child

Which disciplinary techniques are usually effective, and with what types of problem(s)? _____________

Which disciplinary techniques are usually ineffective, and with what types of problems? _____________

___________________________________________________________________________________

On the average, what percentage of the time does your child comply with requests or commands? _____

___________________________________________________________________________________

What have you found to be the most satisfactory ways of helping your child? ______________________

___________________________________________________________________________________

What are your child’s assets or strengths? __________________________________________________

___________________________________________________________________________________

Is there any other information that you think that may help me in assessing your child?

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

exhibit d. sample letter to parents about

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