14-25 Plaza Rd N Ste N-2-7
Fair Lawn, NJ 07410

Psychologist Lic. # 1942                                                                                            201-445-4310 -voice
                                                                                                                              201-444-0698 fax

Name:  ________________________                                    DOB: __________

Address: __________________________________Phone _____________

When did you first begin to think that your child might be intellectually gifted ?  

When did your child begin to speak ? __________   Words _____  Sentences _______

When did your child begin to walk ? __________      Motor Skills ________

Describe his/her social skills ?

Does your child read any basic words ? ______________________________

When did your child begin to read ?   _______________________________

Describe beginning or early reading experiences?  __________________________

What are your child’s main interests at the present time?

Does your child have or did he/she have any very intense interests.  Please describe

Do you have any concerns regarding your child’s social or emotional development?
Please list and describe concerns.

Please write a description of your child. Describe your child to me. His/her likes dislikes, personality, interests anecdotes that reflect
his/her personality.  Why you think he or she might be intellectually gifted.
Make any comment you feel would be help me to understanding your child. Plea
se give me enough information to gain an
understanding of your child.


I give consent to Dr. Granelli to conduct formal intelligence testing.  I understand that the purpose of this testing is for
determination of IQ and is not a diagnostic evaluation.

Parent ______________________