Parent/Guardian Questionnaire
Confidential Intake Form for Families. This form is designed to help us understand your child’s needs holistically. All information provided will remain confidential and used solely for the purpose of supporting your child’s development here at Growing Nurtured Minds™. If you have any questions please email us at info@growingnurturedminds.com
Child's Full Name:
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Date of Birth
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
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Primary Language(s) Spoken at Home:
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Parent/Guardian Name(s):
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Relationship to Child:
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Father
Mother
Other
Contact Information (Phone & Email):
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Home Address:
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Emergency Contact Name, Relationship, Phone Number
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Current School/Program (If Applicable)
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Grade level:
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Has your child ever received special education services or accommodations? Yes or No? If Yes, please describe.
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Has your child been assessed for learning difficulties? Yes or No? If Yes, please provide details.
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What are your child's academic strengths?
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What academic challenges does your child face?
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Has your child ever had an Individualized Education Plan (IEP) or 504 Plan? Yes or No?
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Yes
No
I do not have access to the paperwork currently
Has your child ever had an Individualized Education Plan (IEP) or 504 Plan? If Yes, please provide a copy or summary.
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Has your child ever repeated a grade? Yes or No? If yes, which grade(s)?
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Has your child ever been homeschooled? Yes or No? If yes. for how long?
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Has your child been diagnosed with any learning disabilities?
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No
Dysgraphia
Dyscalculia
Auditory Processing Disorder
Visual Processing Disorder
ADHD
Autism Spectrum Disorder
Other (please specify)
What strategies or interventions have helped your child succeed academically?
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Does your child have any sensory sensitivities (e.g., loud noises, textures, lights)? Yes or No? If Yes, please describe:
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Does your child have any motor skills challenges (e.g., difficulty with handwriting, coordination issues)? Yes or No? If Yes, please elaborate.
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Does your child have any difficulties with speech, language, or communication? Yes or No? If Yes, please explain.
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Has your child ever received speech therapy?
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Does your child have any diagnosed medical conditions? Yes or No?If Yes, please describe:
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Is your child currently on any medications? Yes or No? If Yes, please list:
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Has your child ever been diagnosed with a mental health condition (e.g., anxiety, ADHD, depression, etc.)? Yes or No? If Yes, please specify:
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Has your child received counseling, therapy, dyslexic therapy, or academic tutoring in the past? If Yes, please describe the type and duration:
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Has your child experienced any significant trauma or stressful life events that have impacted him/her academically now or in the past? Yes or No? If yes, please explain (optional)
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How does your child typically interact with peers?
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Outgoing &Social
Shy & Reserved
Has difficulty making friends
Other
What is your child's attitude towards academics? (e.g., lacks motivation, school refusal, test anxiety)
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How does your child respond to frustration or disappointment?
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Easily Upset
Handles Well
Needs Support in Managing Emotions
Other
Are there any behavioral concerns at home or school? Yes or No? If Yes, please describe
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What are your child's favorite activities or hobbies?
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What are your child's biggest social or emotional challenges? (If Applicable)
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How does your child typically express emotions (e.g., talking, withdrawing, acting out)? (If Applicable)
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How much time does your child spend on screens (TV, computer, tablet, phone) daily?
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Does your child use any educational apps or online learning tools? Yes or No? If Yes, please list:
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Who lives in the household?
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Are there any significant stressors (e.g., divorce, loss, financial hardship)? Yes or No? If Yes, please explain (optional)
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Does your family have a strong support system (Extended family, friends, community)? Yes or No? Please describe:
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What are your family's goals for your child's experience at Growing Nurtured Minds ™ ?
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How can we best support your child's growth and development?
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Is there anything else you would like us to know about your child?
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