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Your Child Through Your Eyes
Since no one knows your child better than you do, this intake survey was created to help me learn more about your loved one. If you are interested in having a phone call intake conference to discuss specific concerns or situations, please contact me to schedule a time.
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* Indicates required question
Child's Name
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Your answer
Names of Parents/Guardians
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Your answer
Preferred E-mail Address
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Your answer
List 3 words that describe your child (Feel free to describe as needed)
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Your answer
Select your child's current level of schoolwork independence
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Primarily needs parental/caregiver help throughout tasks
Needs some parental/caregiver help throughout tasks
Needs minimal parental/caregiver help throughout tasks
What hobbies/interests does your child enjoy being involved in outside of school?
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Your answer
What are your child’s strengths in school?
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Your answer
In what areas do you feel your child could improve?
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Your answer
Describe a success your child experienced last spring with remote learning.
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Your answer
Describe a challenge your child experienced last spring with remote learning.
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Your answer
What goals would you like to see your child accomplish this year?
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Your answer
Select your child's remote learning situation.
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Working at home with a parent
Working at home with a caregiver
Working outside the home with a caregiver
A combination of at home and outside the home
Is there any additional information unique to your child's remote learning situation that will be important for me to know?
Your answer
Briefly describe any allergies/health concerns your child may have. (Note: Be sure to share this information with the school nurse as well.)
If you are uncomfortable writing them, we can conference about them at a later time.
Your answer
Indicate any significant experiences/family concerns you feel may impact your child (i.e. a serious illness, loss, relocation)
If you are uncomfortable writing them, we can conference about them at a later time.
Your answer
Please let me know if you have any further comments, concerns, or questions.
Your answer
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