Rebecca Elman, Ph.D., P.A.Licensed Psychologist
Contact Dr. Elman561-470-8660
Before your appointment

Gifted Testing Forms

Please complete these forms only after scheduling an appointment with Dr. Elman.

Gifted Testing Policies and Card Authorization

Your appointment is not confirmed until you complete this form and receive an acknowledgment text from Dr. Elman. No payment is charged during card setup.

Review Policies and Save Card

Before testing, complete and submit both forms below.

Background Information Form – Gifted AssessmentComplete form

Rebecca Elman, Ph.D., P.A.
Licensed Psychologist
1875 NW Corporate Boulevard, Suite 100
Boca Raton, Florida 33431
561-470-8660 · rebeccaelman@gmail.com

Required fields are marked with an asterisk (*).

Student Information

Student's Name:
Calculated from date of birth, in completed years.

Reason for Referral

Who initiated the referral for gifted evaluation?

Family Information

Parent/Guardian 1:
Address
Parent/Guardian 2: (optional)
Address (optional)
Parents are:

Siblings:

Sibling 1

Name (optional)
Enter school name, “Not yet in school,” or “Homeschooled.”

Sibling 2

Name (optional)
Enter school name, “Not yet in school,” or “Homeschooled.”

Sibling 3

Name (optional)
Enter school name, “Not yet in school,” or “Homeschooled.”

Developmental and Medical History

Were there any significant complications during pregnancy, delivery, infancy, or early childhood?
Were your child's early developmental milestones generally achieved within expected timeframes?
Does your child have any significant medical, neurological, developmental, or psychological history that may be relevant to the evaluation?
Is your child currently taking any medication?
Has your child ever received speech/language therapy, occupational therapy, physical therapy, counseling, or other intervention?

Most recent hearing screening/evaluation:

Most recent vision screening/evaluation:

Does your child wear glasses or contact lenses?
Does your child have any fine-motor difficulties that could affect activities involving drawing, writing, or manipulating materials?

Educational History

Teacher: (optional)
Has your child received any advanced, accelerated, gifted, enrichment, remedial, or other specialized educational services?
Has your child previously undergone any psychological, psychoeducational, gifted, developmental, speech/language, occupational, physical, or other evaluation?

Social, Behavioral, and Learning Characteristics

Does your child have any significant difficulties with attention, impulsivity, anxiety, behavior, frustration tolerance, or adjusting to new situations?
Parent/Guardian Signature

Approving this form does not send it. When both forms are approved, submit them together using the encrypted submission button below. You may also download a copy for your records.

Authorization for Communication with Teachers and School PersonnelComplete form

Rebecca Elman, Ph.D., P.A.
Licensed Psychologist
1875 NW Corporate Boulevard, Suite 100
Boca Raton, Florida 33431
561-470-8660 · rebeccaelman@gmail.com

Required fields are marked with an asterisk (*).

AUTHORIZATION FOR COMMUNICATION WITH TEACHERS AND SCHOOL PERSONNEL

Dr. Elman may find it helpful to communicate with your child's teacher or other school personnel about your child's academic performance, classroom behavior, motivation, and learning needs. Please indicate whether you authorize this communication.

Please select one:

Dr. Elman will not contact your child's teacher or other school personnel unless you affirmatively select YES.

Child’s Name:
Parent/Guardian’s Signature:

Approving this form does not send it. When both forms are approved, submit them together using the encrypted submission button below. You may also download a copy for your records.

Submit Your Background and School Communication Forms

Complete and approve both forms above. Once both are approved, select Generate Combined PDF, then follow the instructions to submit them to Dr. Elman.

  • Background Information Form – Gifted AssessmentNot completed
  • Authorization for Communication with Teachers and School PersonnelNot completed

0 of 2 forms approved.

Keep this page open until your submission is confirmed. Leaving or refreshing the page will clear your answers.

Your forms are encrypted before submission. The Gifted Testing Policies and Card Authorization form is submitted separately.