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Parent/Guardian Questionnaire
Date
*
Parent/Guardian's Full Name #1
*
Preferred Contact Information (cell and/or email)
*
Parent/Guardian's Full Name #2
Preferred Contact Information (cell and/or email)
Student’s Name
*
Date of Birth
*
School/Grade
Does your child currently have an IEP?
*
Yes
No
Does your child currently have a 504 Plan?
*
Yes
No
Provide your child’s disability as written in current IEP/504 Plan
What are you child's academic strengths (i.e, reading, math, etc.)?
What subjects in school does your child struggle or find challenging?
Is your child assigned homework?
Yes
No
Homework Completion Frequency. Please describe.
Is your child reading at grade level?
Yes
No
Is your child performing at grade level in math?
Yes
No
Has your child had a formal educational evaluation?
Yes
No
Has your child been suspended from school?
Yes
No
Has your child been expelled or referred to an alternative placement?
Yes
No
Teacher Concerns About Behavior. Please describe.
How does the school describe your child's behavior (i.e., aggression toward staff/peers, etc.)
Has your child been referred for Functional Behavior Analysis (FBA)/ Behavior Intervention Plan (BIP)?
Yes
No
If yes, does your child currently have a BIP/FBA?
Yes
No
Has your child received mental health counseling?
Yes
No
Is your child currently in therapy?
Yes
No
Has counseling been helpful? Please describe.
Does your child need mental health support?
Yes
No
Does your child take medication?
Yes
No
List of Medications
Does your child receive Related Services in IEP (check all that apply)?
Occupational Therapy
Speech and Language Therapy
Physical Therapy
Nursing Services
One-on-One Aide
Other
If you selected other, please describe below:
Are you open to Evaluations for Learning/Behavioral Challenges?
Yes
No
What concerns are not being addressed at school?
What goals do you have for your this school year?
What essential supports, accommodations and services does you child need?
Additional Information
Submit
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