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BTA Parent/Guardian Questionnaire
By completing this form , we will have a better focus point for the consultations that will provide insight, tools, and understanding of how to address the needs of your learner.
* Indicates required question
Email
*
Record my email address with my response
Date
*
MM
/
DD
/
YYYY
Parent/Guardian Name
*
Your answer
Relationship to learner
*
Your answer
Phone number
*
Your answer
Email Address
*
Your answer
Preferred Method of Contact
*
Phone Call
Email
Text
Zoom/Google Meets
Required
Learner's Name and D.O.B.
*
Your answer
Does the student have an exceptionality (ie. Autism, ADHD, TBI, Dyslexia, MID)? If so, please list it.
*
Yes
No
Other:
Required
Current Grade and School District
*
Your answer
Is there currently an IEP or 504 in place?
*
Yes, my learner has an IEP.
Yes, my learner has a 504.
No, my learner does not have and IEP or 504.
I am unsure.
Areas of Concern
*
Academics (Math, Reading, Writing)
Social/Emotional/Behaviors at school
Social/Emotional/Behaviors at home
Following directions
Task Completion
Schedules and Routines
IEP Support
Other
What goals do you hope to achieve during your consultation?
*
Your answer
Consent and Acknowledgement:
*
I understand that this intake form is for the purpose of identifying educational and behavioral support needs.
I understand that the consultant will not share information without consent and will use it solely to guide service recommendations.
Required
Send me a copy of my responses.
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