Questionnaire For Parents

QUESTIONNAIRE FOR PARENTS
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Thank you for making the time to complete this questionnaire regarding your child. Please answer each question as honestly as you can -- there are no right or wrong answers. In each question, you will be asked to show the extent to which you agree or disagree with a statement. If you strongly agree with a statement, circle the number ⑦. If you strongly disagree with a statement, click ①. If your feelings are not strong or neutral, click on one of the numbers in the middle. Thank you.

Please complete the following statements from your perspective:
1. I wish I could help my child:
2. What I love about being a parent to my child is:
3. The ideal education for my child would be (i.e., public, private, homeschool, unschooling, other):
4. My greatest challenge as a parent/caregiver is:
5. My greatest strength as a parent/caregiver is:

Please complete the following questions:
1. What are your overall hopes and dreams for your child?
2. What are greatest concerns regarding your child, or your relationship with your child, at this time?
3. What outcome would you most like for your child at this time?
4. Do you have anything else you would like to add, or anything that you feel would be helpful to you?

	1	2	3	4	5	6	7
1. Responds to questions slowly
2. Is intelligent but has trouble with school
3. Asks deep, thought-provoking questions
4. Seems to arrive at (i.e., math, science) solutions in a unique and different way
5. Has been given labels such as: ADHD, Dyslexic, Autism, 2e, or other
6. Jumps from topic to topic
7. Is highly verbal
8. Avoids work that seems complicated or hard
9. Has difficulty doing things in sequential order
10. Needs frequent reminders to complete daily tasks
11. Acts on impulse
12. Has difficulty paying attention; easily distracted
13. Runs out of energy before finishing homework
14. Has trouble completing tasks
15. Has intense focus on areas or interest or passion
16. Is forgetful
17. Has a photographic memory for learning
18. Takes in all the visual stimuli of their environment noticing the slightest changes
19. Is highly talented in a specific area

	1	2	3	4	5	6	7
1. Is often bothered by tags, itchy/tight clothing, or sock seams
2. Does not like loud, unexpected sounds such as sirens
3. Does not like crawling/walking barefoot on course carpet/grass
4. Upset by transitions and unexpected changes
5. Walks on tiptoes
6. Often unaware of body sensations such as hot/cold, hunger
7. Makes sound, noises, squeezes or touches things to self-soothe/regulate
8. Sensitive to food textures, temperature and spice
9. Doesn’t seem to notice when touched
10. Easily exhausted
11. Is impatient when they don’t have something to do
12. Does not have a daily routine
13. Likes sports that involve a physical thrill

	1	2	3	4	5	6	7
1. Makes friends easily
2. Loves fantasy worlds
3. Struggles to fit in
4. Has frequent meltdowns or outbursts
5. Learns better from a gentle correction than strong punishment
6. Loses interest in something they love when it becomes performative
7. Is very sensitive to pain
8. Performs better when strangers aren’t present
9. Seems very intuitive
10. Can be rigid or inflexible
11. Is a peacemaker
12. Likes to please
13. Is sensitive
14. Struggles with rules and regulations that don’t make sense
15. Prefers quiet play
16. Has a hard time making friends
17. Prefers to be alone
18. Considers if something is safe before engaging
19. Is someone others go to as a problem solver

	1	2	3	4	5	6	7
1. Self-worth is linked to their achievements
2. Is high-functioning, but struggles with anxiety, depression, or burnout
3. Feels as if they are under a spotlight
4. Bases their worth on appearance, achievement, or possessions
5. Sets unrealistic standards, puts pressure on themselves, or fears failure
6. Is always busy and struggles with stillness
7. Has high expectations of themselves and others
8. Has a harsh inner critic (it's my fault, what's wrong with me, I'm so dumb)
9. Uses accomplishment as a form of self worth rather than inner inspiration
10. Struggles with self-doubt
11. Spends more time alone now than usual
12. Experiences tics, obsessive-compulsive or ritualistic behaviors
13. Has brain fog, difficulty focusing on daily tasks, or making decisions
14. Often feels fatigued or complains of headaches, stomaches, or other illnesses
15. Has experienced weight loss or weight gain
16. Isn't sure what they like anymore
17. Personalizes comments or actions by others frequently (i.e., I caused it)
18. Has trouble sleeping or sleeps excessively but never feels rested
19. Uses external supports (gaming, pleasing, etc.) to avoid feeling

	1	2	3	4	5	6	7
1. Can sense and feel energies
2. Is highly intuitive
3. Senses when people are not being honest
4. Responds more to how people feel than what they say or do
5. Has a heightened sensory system
6. Seems to read my mind
7. Knows things without being told
8. Struggles in large groups of places with high stimulation or noise
9. Has imaginary friends
10. Makes up different languages
11. Cares about the well-being of earth
12. Has a deep connection to animals, nature and all life forms
13. Mirrors the feelings and thoughts of others
14. Feels other people’s emotions; highly empathic or notices distress of others
15. Has a strong sense of justice and fairness
16. Startles easily
17. Has trouble sleeping at night, night terrors/bad dreams, or is afraid of the dark
18. Either likes or avoids certain locations or people