LEARNING / EDUCATION Highest Level of Education Completed: (If patient states otherwise, note difference in information in the comments field.) 1 year college completed    Associate’s Master’s 2 years college completed Never attended school    Bachelor’s  3 years college completed  Doctorate  Pre-School / Kindergarten 4 + years college completed GED Special Ed / Emotional handicap     Trade or Business college 4 yrs college completed *(Grade 1-12) Indicate highest level ____   ______________________________________ Unknown  Education Program Type:  Special education  Gifted  Home schooled Regular Other Unknown    DIPLOMA: Special Education Type: Emotional disability Learning disability GED High school College      None Other    Other  Unknown Education Comments: Are You Interested in Increasing Your Academic Skills or Working Toward Your GED?  No  Yes Academic Skills / GED Comments: Reading Ability:  No  Yes  Limited (Describe in comments how ability was assessed) Reading Ability Comments: (Use standardized paragraph and address accordingly.) 4
LEARNING / EDUCATION Highest Level of Education Completed: (If patient states otherwise, note difference in information in the comments field.)  1 year college completed  2 years college completed  3 years college completed  4 + years college completed  4 yrs college completed  Associate’s  Bachelor’s  Doctorate  GED  *(Grade 1-12) Indicate highest level ____ ______________________________________  Master’s  Never attended school  Pre-School / Kindergarten  Special Ed / Emotional handicap  Trade or Business college  Unknown Education Program Type:  Special education  Regular  Gifted  Other  Home schooled  Unknown Special Education Type:  Emotional disability  Learning disability  Other  Unknown DIPLOMA:  GED  High school  College  None  Other Education Comments: Are You Interested in Increasing Your Academic Skills or Working Toward Your GED?  No  Yes Academic Skills / GED Comments: Reading Ability: (Describe in comments how ability was assessed)  No  Yes  Limited Reading Ability Comments: (Use standardized paragraph and address accordingly.) 4
54573%20(1-11)%20cws%20rehabilitation%20initial%20assessment.docx