BRYAN F. GRANELLI, Ph.D.
14-25 Plaza Rd N Ste N-2-7
Fair Lawn, NJ 07410
Psychologist Lic. # 1942 201-445-4310 -voice
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. Please 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.