Parent Questionnaire and Update
Child’s Name:__________________________________________________________________
Person completing this form:_______________________________________________________
Marital Status of Parents:__________________________________________________________
If parents are separated or divorced, how old was the child when the separation occurred:
______________________________________________________________________________
What are your child’s main interests and strengths both academically and socially? ______________________________________________________________________________
______________________________________________________________________________
What are you child’s difficulties both academically and socially?
______________________________________________________________________________
______________________________________________________________________________
Does your child make friends and interact with peers: (Describe types of interactions, play, or activities observed most often, leadership skills, gets along with most people)? ______________________________________________________________________________
______________________________________________________________________________
Have any inappropriate behaviors occurred in the household recently: (Please list and describe)? ______________________________________________________________________________
______________________________________________________________________________
Have any developmental delays or medical problems occurred recently:(Please list and describe)? ______________________________________________________________________________
______________________________________________________________________________
How would you rate your child’s work habits at home? (Uses to his advantage inconsistent, poor, no habits observed) ______________________________________________________________
______________________________________________________________________________
How would you rate your child’s interest in school? (Almost always interested, often interested but loses interest, uninterested but at times shows real interest, not interested): _______________
______________________________________________________________________________
How would you rate your child’s education progress: (Making progress beyond expectation, adequate, some difficulties, substantial difficulties) _____________________________________
______________________________________________________________________________
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