Parent Questionnaire
Student Information
Student Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
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School
Currently attending
Grade
Select Current grade
Preschool
JK
SK
1
2
3
4
5
6
7
8
Secondary School
StudentID
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Parent Information
Parent/Guardian Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
-
Area Code
Phone Number
Cell Phone
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
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Parent Information
Parent/Guardian Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
-
Area Code
Phone Number
Cell Phone
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
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School History
What schools has your child attended? Please list all schools and the grades attended there.
In-School Support
Please describe any additional assistance your child currently receives at school (e.g. Learning Centre, Special Education Class, In-class support).
Extra-curricular support
Is your child receiving extra help outside school (e.g. tutoring, speech therapy, occupational therapy, etc.) Include the type of therapy, name of the therapist and the frequency (e.g. number of times per week).
Assessments and Reports
Please list any previous assessments your child has had (e.g. academic, psychological, speech and language, occupational therapy). Include the date of assessment and the name of the professional who completed the report
Referred by
Who referred you to Angus Lloyd Associates?
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Areas of concern
complete all applicable sections
Reading
Reading
Major concern
Minor concern
No concern
not applicable
sounding out new words
remembering words he/she has read
reading too slowly
knowing word meanings
understanding facts
getting the main idea
drawing conclusions
doesn't like reading
Comments
Spelling
Spelling
Major concern
Minor concern
No concern
not applicable
can't recall spelling words
"invents" spelling when writing
doesn't know or apply spelling rules
Comments
Written Language
Written Language
Major concern
Minor concern
No concern
not applicable
doesn't use grammatically correct sentences
does not use capitals properly
does not use punctuation properly
does not have good ideas for stories
has trouble sequencing events in a story
Comments
Mathematics
Mathematics
Major concern
Minor concern
No concern
not applicable
had difficulty learning to count
can't remember basic math facts
can't do simple addition or subtraction problems
difficulty telling time
difficulty with story problems
has difficulty counting and working with money
trouble understanding fractions
Comments
Attention and Behaviour
Attention and Behaviour
Major concern
Minor concern
No concern
not applicable
restless or overactive
excitable, impulsive
disturbs other children
fails to finish things he/she starts - short attention span
constantly fidgeting
inattentive, easily distracted
demands must be met immediately
cries often and easily
mood changes quickly & drastically
temper outbursts, explosive and unpredictable behaviour
Comments
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Medical History
Has your child been diagnosed for any medical conditions that we should know about (e.g. asthma, allergies, seizure disorders)?
Goals for Support
What do you hope will be the outcome of this referral?
Previous reports
Browse Files
If you have any previous assessment reports or other documents you would like us to see you may upload them here.
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