Name *

First Name

Last Name

Students Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Student General Characteristics (Karakteristik Umum) Appears bright. highly Intelligent, and articulate but unable to read, write, or spell at grade level. (Tampak cerah, sangat cerdas dan pandai bicara tetapi tidak bias untuk membaca, menulis atau mengeja di tingkat kelas)

Yes

No

Sometimes

Is your student labeled lazy, dumb, careless, Immature, not trying hard enough “ or ‘a behavior problem. (Berlabel malas,bodoh, ceroboh, belum dewasa, tidk berusaha cukup keras or masalah perilaku)

Yes

No

Sometimes

Does your student have a high IQ, yet may not test well academically: tests well orally, but not written (IQ tinggi,namun banyak yang tidak lulus dengan baik secara akademis: test dengan baik secara lisan, tapi tidak tertulis)

Yes

No

Does your student feels dumb: has poor self-esteem; hides or covers up weaknesses with ingenious compensatory strategies. (Merasa bodoh, memiliki kepercayaan diri yang kurang: menyembunyikan atau menutupi kelemahan dengan strategi konpensasi yang cerdik)

Yes

No

Sometimes

Your student is easily frustrated and emotional about school, reading or testing. (Mudah emosi dan frustasi tentang sekolah, membacakan ujian sekolah)

Yes

No

Sometimes

Does your student feels dumb: has poor self-esteem; hides or covers up weaknesses with ingenious compensatory strategies. (Merasa bodoh, memiliki kepercayaan diri yang kurang: menyembunyikan atau menutupi kelemahan dengan strategi konpensasi yang cerdik)

Yes

No

Sometimes

Is your student easily frustrated and emotional about school, reading or testing. (Mudah emosi dan frustasi tentang sekolah, membacakan ujian sekolah)

Yes

No

Sometimes