CHILD INTERVIEW

Student:                                                  DOB:                          Grade:          Date:                         

Teacher:                                                  School                                                         

Name of Interviewer/Position:                                                                                         

Reason for Interview (circle one):         a. Full Case Study        b. Re-Evaluation Conference        c. Change of Program

School

Favorite Subject:                                                 Least Favorite Subject:                                 

Reason:                                                         Reason:                                                 

Good Things About School:                                                                                                                                                                                                                         

Bad Things About School:                                                                                                                                                                                                                         

Self

Favorite Thing About Self:                                                                                                 

Thing That You Want to Change:                                                                                         

Birthday:                                                                 Phone #:                                         

Address:                                                                                                                                                                                                                                         

Favorites

Book:                                                                 Movie:                                                         

TV Show:                                                         Game:                                                         

Friends

Names:                                                                                                                                                                                                                                         

What Do You Like About Them?                                                                                                                                                                                                                 

What Do You Do Together?                                                                                                                                                                                                                         

Family

Who Do You Live With?                                                                                                                                                                                                                         

How Do You All Get Along?                                                                                                                                                                                                                         

What Do You Do Together?