Child’s Name   Date of Birth

 Your Name   Relationship to Child

 Telephone Numbers

   A. What learning problems has your child been diagnosed with?

   B. Is there a family history of learning problems or attentional disorders?

 C. In what areas does your child need help?

 D.  What has been done/is being done to help your child in school?

 On a scale of 1-5 rank your child’s ability in the following areas. Please check a number.

 1- Excellent     2- very good    3- average        4- struggles, has trouble            5- extremely difficult

 Playing Team Sports                                      1          2          3          4          5         

 Playing Individual Sports                              1          2          3          4          5

 Climbing, running, jumping                          1          2          3          4          5

 Catching, throwing, kicking                          1          2          3          4          5

 Drawing                                                            1          2          3          4          5          

 Painting                                                            1          2          3          4          5

 Crafts                                                                1          2          3          4          5        

 Playing with building toys                             1          2          3          4          5         

 Puzzles                                                             1          2          3          4          5         

 Playing board games                                     1          2          3          4          5        

 Learning rules to games                               1          2          3          4          5         

 Playing with same age kids                          1          2          3          4          5

 Playing with older children                           1          2          3          4          5

 Playing with younger kids                            1          2          3          4          5         

 Following simple directions at home         1          2          3          4          5

 Following complicated or                             1          2          3          4          5         multiple directions at home(Get dressed, tie your shoes, and grab your backpack, or get me the red bowl in the cabinet by the stove)

 Speaking clearly                                           1          2          3          4          5       

 Explaining things                                          1          2          3          4          5

 Remembering where to find things           1          2          3          4          5

 Remembering how to get places               1          2          3          4          5       

 Remembering messages                             1          2          3          4          5     

 Telling left from right                                    1          2          3          4          5         

 Telling time                                                     1          2          3          4          5        

 Using his/her imagination                           1          2          3          4          5         

 Reading words                                               1          2          3          4          5         

 Sounding out words                                     1          2          3          4          5         

 Remembering sight words                          1          2          3          4          5         

 Understanding what he/she read             1          2          3          4          5         

 Reading fast enough                                    1          2          3          4          5        

 Reading aloud                                               1          2          3          4          5         

 Figuring out what new words mean         1          2          3          4          5         

 Remembering what he/she read              1          2          3          4          5       

 Handwriting                                                  1          2          3          4          5        

 Writing sentences/paragraphs                1          2          3          4          5        

 Writing fast enough                                    1          2          3          4          5         

 Spelling test words                                     1          2          3          4          5        

 Everyday spelling                                       1          2          3          4          5         

 Learning math                                             1          2          3          4          5          

 Remembering math facts                         1          2          3          4          5         

 Doing well on math tests                          1          2          3          4          5         

 Avoiding careless math mistakes           1          2          3          4          5         

(Adding instead of subtracting, forgetting to carry)

 Completing homework                              1          2          3          4          5         

 Bringing homework home                        1          2          3          4          5         

 Turing in homework                                   1          2          3          4          5         

 Knowing what to study                             1          2          3          4          5         

 Learning new words                                  1          2          3          4          5       

 Memorizing things for school                  1          2          3          4          5         

 Music                                                           1          2          3          4          5        

 Art                                                                1          2          3          4          5         

 What is your child’s favorite subject?  Why do you think it is his/her favorite?

 What is your child’s least favorite subject?  Why do you think it is his/her least favorite?

 What activities does your child like to do for fun?

 Does your child participate in any after school activities (sports, scouting, church groups)

 How does your child feel about school?

 What is homework time like at your house?

 Do you have any ideas or suggestions as to what works well for you child?

 Anything else we should know?

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