[Imported] Teacher Input Form

Teacher Input Form

If you are receiving this form, it is because we received a release from the student's parent to get your input. If you would like a copy of the release first, please email support@claritypsychologicaltesting.com and we will provide a copy. Thank you for taking the time to provide us with your invaluable input.
Parents do not receive a copy of this raw data, but relevant responses will be summarized and cited in the report when needed to support a diagnosis. Teachers have such a valuable lens and one that is integral to the assessment process in terms of understanding if the student's issues are pervasive throughout all domains of their life or isolated to only a few areas of functioning. In the space below, please provide your name, grade taught/role, and school info:
Date

MonthDayYear
Date
Student's Name*
In what capacity do you work with this student?
How would you rate the student's ability to pay attention in class?

1

2

3

4

5

1 is Worst, 5 is Best
How would you rate the student's ability to develop and maintain social connection at school?

1

2

3

4

5

1 is Worst, 5 is Best
Are you noticing any concerns around the autism spectrum for this student?

Repetitive behaviorsMaladaptive speechSocial alienationperseveration on the same topicsseems to talk "at" others vs. with otherssubject to bullying or being made fun of a lotlack of social or emotional reciprocity (lack of eye contact, humor seems to go over their head, doesn't understand neologisms "it's raining cats and dogs," prefers to play alone or with different age group)adaptive functioning concerns (hygiene, lack of grooming, unkempt appearance, doesn't seem to have capacity to do same responsibilities as same age peers)sensory issues, auditory sensitivity, tactile sensitivity, clothing issues, etc.Other
How would you rate the student's participation in extracurricular activities (sports, student council, drama club, choir, volunteering, etc.) with 5 being the most participation?

1

2

3

4

5

1 is Worst, 5 is Best
What are the most salient symptoms, challenges, or issues you are observing in the course of your work with them? (anger, social impairment, lack of insight, trauma, depression, disordered eating, family issues, self-esteem issues, disorganization, too much social media, isolation, academic issues, hyperactivity, forgetfulness, distraction, defiance, irritability, family issues)
How would you rate the student's motivation to do well in school?
How would you rate the student's motivation to do well in school with 5 being the best?

1

2

3

4

5

1 is Worst, 5 is Best
Social Functioning : do you see them regularly hanging out with the same friends at school? do they isolate? are you concerned they might be being bullied? do they struggle with social skills?
How would you rate the student's participation in extracurricular activities (sports, student council, drama club, choir, volunteering, etc.)
Family Functioning: Is there anything relevant to their family that might help understand them better? How is the parents involvement with their child's learning?
ADHD Concerns: Are you noticing anything that might be indicative of ADHD like impulsivity, hyperactivity, inattention, lack of motivation, homework issues, emotional disinhibition? Failing grades? Missing steps?
Any concerns around oppositionality? antisocial tendencies? being untrustworthy? stealing? destroying property? violence? aggression? manipulation? lack of empathy or compassion? lack of remorse?
Anything else that is important to consider when doing testing with this patient?
Thank you again for taking the time to fill out this form. If you feel that other students might benefit from testing to gain diagnostic clarity and better treatment planning, please visit the link attached here to refer. We accept most major insurance plans making this testing affordable and accessible for all students.
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