QUESTIONNAIRE

The following form lists questions to help better understand your child and their needs. Please be as detailed as possible, remembering that all children and circumstances are unique!

PARENT / GUARDIAN INFORMATION

First Name

Last Name

PHONE

(###)

###

####

STUDENT INFORMATION

First Name

Last Name

AGE & GRADE

WHICH SERVICE(S) IS THE STUDENT INTERESTED IN?

WHAT SCHOOL DOES THE STUDENT ATTEND?

IN A FEW SENTENCES, PLEASE EXPLAIN THE CHILD AS A PERSON.

IN A FEW SENTENCES, PLEASE EXPLAIN THE CHILD AS A STUDENT.

WHAT ARE SOME OF THE STUDENT'S INTERESTS?

WHAT ARE SOME OF YOUR CHILD'S STRENGTHS?

WHAT ARE SOME OF YOUR CHILD'S WEAKNESSES?

WHAT ARE SOME GENERAL GOALS FOR THE CHILD?