• 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)

  • *

  • SECTION 3 — AGE & LOCATION (REQUIRED)

  • Is the New Driver?*
  • City?*
  • State?*

  • 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)*
  • Does the new driver experience challenges related to learning, anxiety, attention, autism, or other cognitive or executive-function barriers?*
  • Is your family prepared to commit to regular practice and participation if accepted into the program?*
  • Do you understand that this program is specialized, individualized, and not a traditional driver education course?*

  • SECTION 5 — HIGH-LEVEL DISCLOSURE (SHORT ANSWER)

  • Briefly describe the primary challenges or concerns related to driving.*

  • 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. *

  • SECTION 7 — SUBMIT

  • Should be Empty: