Exceptional Learner Driver Program Pre-Screen Questionnaire
SECTION 1 — This short questionnaire helps us determine whether our specialized driver education program is a good fit for your needs. Completion of this form does not guarantee acceptance into the program. If appropriate, you will be invited to complete a full intake form and schedule a driving evaluation.
SECTION 2 — BASIC CONTACT INFO (REQUIRED)
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SECTION 3 — AGE & LOCATION (REQUIRED)
Is the New Driver?
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City?
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State?
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SECTION 4 — READINESS QUESTIONS (ALL REQUIRED)
Does the new driver have a learner’s permit or driver’s license? (Note: “No” is acceptable at this stage)
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Does the new driver experience challenges related to learning, anxiety, attention, autism, or other cognitive or executive-function barriers?
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Is your family prepared to commit to regular practice and participation if accepted into the program?
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Do you understand that this program is specialized, individualized, and not a traditional driver education course?
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SECTION 5 — HIGH-LEVEL DISCLOSURE (SHORT ANSWER)
Briefly describe the primary challenges or concerns related to driving.
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SECTION 6 — EXPECTATION SETTING (REQUIRED ACKNOWLEDGMENT)
Please read each statement and check the appropriate box. If all are not checked, we will be unable to proceed at this time.
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SECTION 7 — SUBMIT
Submit
Should be Empty: