Parent Instructions


In the box to the right enter the information exactly as it appears on the assignment slip given to you by your provider.

Important Note: please be sure and enter the child's full or formal first name. Do not use nicknames (like Bob for Robert or Suzie for Susan). Do not include designations such as Jr, II, etc. behind the last name.

When completing a rating please allow yourself about 15 minutes. Forms not submitted in 30 minutes will have to be reentered.

Please make sure you answer all items before submitting or closing your browser. You are not done until you have reached the final page and then have clicked the Finish button.

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First Name of Child

formal first name
Last Name of Child

last name*
Child's Date of Birth (mm/dd/yyyy)
month* day* year*
Case Number

Clinic ID

Rating form
initial assessment*
follow-up assessment*