Homework Coaching Program Background Questionnaire [for parents]

HW Coaching Program Background Questionnaire

[for Parents/Guardians]
Parent/Caregiver Name

First NameLast Name
Parent/Caregiver Email
example@example.com
Parent/Caregiver Phone
Area Code - ??? - ????
Your Home Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Teen's Name

First NameLast Name
Teen's Birthdate

MonthDayYear
Date
Teen's School
Teen's Grade
Teen's Gender
Pronouns
What led you to seek HW Coaching for your adolescent now?
What are your main concerns about your teen's homework habits?
How long ago did your concerns start?

To what extent do your teen's problems interfere with their ability to function in each area of life?

Rows	Never/Rarely	Sometimes	Often	Very Often
Friendships?
Family Relationships?
In School?
In Class
Daily chores or activities?

Does your teen have any pressing life stressors? (anything you think is stressful for your teen, including relationships, school, health, college...)

Medical History

Rows	Age 0-24 months	Age 2-5 years	Age 6-12	Age 13-18	>Age 18
allergies
heart problems
epilepsy
high blood pressure
head injury/concussion
encephalitis/brain infection/tumor
lead poisoning
surgeries
migraine headaches
thyroid condition
vision problems
hearing problems
Type 1 or 2 Diabetes
liver disease
involuntary movements
vocal tics/noises
persistent depression
persistent anxiety
sleep problems
eating problems
clumsiness
other

Describe any other medical problems, besides those listed above.
On average, how many hours of sleep does your teen get each night?
Is your teen in counseling or therapy now, or been in therapy? Please detail:
never or rarelya few times/month1-2 times/week3-4 times/weekalmost every nightOther
Please list CURRENT and PAST medications your teen has taken regularly for physical or mental health issues. Include all over-the-counter meds, herbs & supplements
Has your teen been hospitalized or had major surgery? Please provide details including age it occurred.
Did someone smoke cigarettes, use alcohol or illicit drugs near you during your pregnancy? Please detail:
Do you recall any problems during pregnancy, labor, or delivery with your teen? Please detail:
If you recall, what was your teen's birth weight and length at birth?
Did your teen sit up, walk, and talk at expected ages? If not, please provide details:
quietactivecolickystubborndefianttemper tantrumssocial and friendlyOther
Describe difficulties your teen had when starting school KG, 1st-3rd grades in reading, writing, & math?
What were your teen's grades in elementary, middle, and high school? What are your teen's most recent grades?
What comments or observation did teachers say about your teen in various grades?
Did your teen have problems getting along with other children? Or with teachers?
Was your teen ever in special ed during school? 504, IEP Please give details:
Has your teen been assessed for ADHD? If yes, describe WHEN, WHERE and BY WHO, and assessment OUTCOME?

Please check the item that best describes your teen's behavior during childhood and adolescence:

Rows	Never/Rarely	Sometimes	Often	Frequently
With homework at home gets distracted and does not complete
When they do complete homework, they often forget to turn it in
When expected to read or do assignments in class, they often are distracted
Had problems learning addition, subtraction, multiplication, or division tables
They say homework is often too difficult for them
Has messy or illegible handwriting
Even if trying hard, they have difficulty reading

During any level of school did your teen show any of these problems?

Rows	Never/Rarely	Sometimes	Often	Frequently
Getting into trouble for talking too much
Getting into trouble for losing their temper
Getting into trouble for being too aggressive or fighting
Getting into trouble for destroying objects
Getting into trouble for defying teachers
Feeling depressed or lonely
Feeling anxious, scared
Being clumsy
Having problems engaging in play activities or doing fun things quietly

cheerful/happysad/depressedanxious/nervousbland/unfeelingangry/irritablechanges all the timeOther
yesnoOther
yesnoOther
Further details or comments on any of the above items.
If applicable, is your teen in a romantic relationship? If yes, how long?
yesnoOther
yesnoOther
Does your teen ever had any legal problems? If yes, please detail:
Is your or has your teen been employed: Where, how long, how often?
To your knowledge, has your teen used any illicit substances? If yes, please detail:

Family history of ADHD/learning difficulties:

Rows	N/A- or don't know	Unlikely	Possible	Likely	Diagnosed
Grandfather(s)
Grandmother(s)
Caregiver (1)
Caregiver (2)
Caregiver (3)
Uncle(s)
Aunt(s)
Brother(s)
Sister(s)

Is there any other information we haven't asked about that might help with providing homework coaching to your child?
Thank you for completing this questionnaire.

We will be in touch with you as soon as possible.
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HW Coaching Program Background Questionnaire

Thank you for completing this questionnaire.