School-Year Programs Educator's Questionnaire

Dear Educator,

You have been asked to complete this form because of your professional relationship with a student who has applied to our school-year program.

Please answer this form as honestly as possible in order to help us determine if the student could be succesful in ADHD Dude programs.

ADHD Dude provides school-year and summer programs for boys who present with ADHD. Our program focuses on improving social skills and executive functioning through an active program. A portion of program time is spent out in the community.

Please note that ADHD Dude programs do not provide a level of support for boys who:

-are prone to physical/verbal aggression, emotional outbursts in school or in public.
-prone to elopement when upset/angry.
-have significant difficulty working in groups with classmates.
-make threats of aggression towards teachers or classmates.
-require 1:1 support in school or are in a self-contained behavioral classroom for the majority of the school day.
-are diagnosed with Asperger’s or higher-functioning autism.
-have anxiety that manifests as negativity/outbursts when in a group setting.
-Need behavioral support in school in the form of a para, 1:1 aide, self-contained emotional support classroom, etc.

We appreciate your cooperation in filling out this form. Please do not hestiate to contact us with any questions at: theadhddude@gmail.com

Student's Name *

Student's Current Grade *

Parent's Name (if different last name than student)

Your Name *

Your school email: *

Relation to the student *

How long have you known student: *

If this student has an IEP what is his educational classification? If no IEP please put "na". *

To your knowledge does this student have an autism spectrum/Asperger's diagnosis? *

Yes No Not sure

Does this student have a history of discipline/behavior issues at your school in the past year? If "Yes" please describe. If no please put "NA" *

Does student receive any support in school for behavioral/emotional challenges? If so, please describe type of support. *

Please describe this student's parents relationship with yourself or school faculty. *

Supportive & Cooperative Accusatory/Combative Varies Tendency to "micromanage" or "helicopter"

How would this student's classmates describe his social interactions with them? *

Is this student able to take directions from classmates and successfully work in a group? *

Yes Yes but requires significant adult intervention Struggles taking directions/working as part of a group Don't observe student doing group work

To your knowledge, has this child ever been aggressive, self-injurious, threatened or expressed suicidal ideation? *

Do you believe this student could be successful in a semi-structured program with similar-age peers? *

Yes No Not sure

Educator's Professional Questionnaire