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Child's Name_______________________
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Date of Birth_______________________
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At home my/our child enjoys:
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I/We have questions or concerns about:
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Goals that I/we would like my/our child to focus on in the following six months:
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What I/we enjoy about my/our child:
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Completed by________________________________
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Date _______________________
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Classroom ___________________________________
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Date _______________________
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Classroom ___________________________________
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Date _______________________
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