Child Questionnaire
Email
Phone Number
What is your name?
What is your child's full name and age?
Is your child in the one of the following :1st -8th grade?
Yes
No
Is your child struggling in reading or math?
Yes
No
Does your child have any learning challenges such as a Disability, IEP, or more?? than 2 grade levels behind?
Yes
No
Does your child wear glasses?
Yes
No
Has your child reported seeing letters move, get blurry or change while reading?
Yes
No
Does your child wear hearing aids or have trouble hearing?
Yes
No
Can your child talk and be understood by people outside of family?
Yes
No
Can your child follow multi-step directions?
Yes
No
Can your child remember what they've learned?
Yes
No
Is your child fully potty trained?
Yes
No
Can they zip or button clothes without help?
Yes
No
Are your child's physical abilities limited in any way?
Yes
No
Can they walk or run without assistance?
Yes
No
Does your child have a hard time staying focused or following directions?
Yes
No
Has your child had academic or learning concerns in previous years?
Yes
No
Can your child make friends easily?
Yes
No
What sparks your child's interest?
What causes your child to become frustrated?
Does your child take any medication that may affect their learning or behavior?
What subject is your child good at?
What area do you believe your child needs the most improvement?
Is there anything else we should know about your child?
What do you expect your child to gain from our tutoring program?
I understand this form is used to determine if my child needs can be met. This form is for our informational use only.
Your Signature
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Date
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