Important Disclaimer: This is an educational advocacy aid only. It does not diagnose any condition, create a legally binding 504 plan, or replace evaluation by qualified professionals (physician, psychologist, school 504 team). Self-report items are simplified educational checklists, not validated clinical instruments. Always consult licensed clinicians and follow your school’s official 504 process. Data stays in your browser only.
Student Self-Report
Parent / Guardian
1. Info
2. Screeners
3. Impact
4. Accommodations
5. Reports
👤 Student Information
Primary Concerns (brief summary)
Next: Self-Report Screeners →
📝 Self-Report Screeners
Rate how often each statement applies over the past 2–4 weeks. These are educational checklists only.
Attention / Focus
Anxiety / Worry
Mood / Energy
Executive Function
Learning / Academic
Sensory / Physical
Social / Communication
Executive Function Domain
Learning & Academic Domain
Sensory / Physical Domain
Social / Communication Domain
← Back
Next: Functional Impact →
📊 Functional Impact in School
Describe how these challenges affect daily school life. Be specific — this helps doctors and the 504 team.
Classroom Participation & Attention
Homework & Assignments
Tests & Quizzes
Organization & Materials
Peer Interactions / Emotional Regulation
Other Areas (attendance, transitions, etc.)
← Back
Next: Accommodations →
🛠️ Requested / Suggested Accommodations
Select all that may help. You can add notes for each. These are common examples — the school team decides final plan.
Additional Notes or Custom Accommodations
← Back
Next: Generate Reports →
📄 Generated Reports
Review, edit if needed, then print or copy for your doctor and school team.
1. Doctor / Clinician Discussion Report
🖨️ Print Doctor Report
📋 Copy to Clipboard
2. Sample 504 Plan Language (Draft for Discussion)
🖨️ Print Sample Plan
📋 Copy to Clipboard
← Back
🔄 Regenerate Reports
🖨️ Print Entire Page
Educational tool only • Data remains in your browser • Not affiliated with any school district or government agency