Parent Questionnaire

Child's Name
Date of Birth
Parent's Name
Parent's Address
Cell Phone
Work Phone
Child's School
Grade Setting
Referred By
Dietary Restrictions
What type of services/interventions does your child receive?

Describe your child's language level.
Single word comprehension 3 to 4 word comprehension 2-3 word comprehension Higher Level Language difficulties
What do you consider to be your child's greatest strengths in relation to social communication?

What do you consider to be your child's weaknesses in relation to social communication?

In what setting if any does your child show greater communicative success? Please describe.

In what setting does your child have the greatest difficulty with social communication? Please describe.

What goals/social language skills would you like to see your child achieve?

Does your child follow safety rules and avoid hazardous situations?

How does your child deal with frustration?

Please describe your child to us including any behavioral challenges/concerns.

Please list your child's hobbies/interests.

What information would you like as a parent to be provided during our quarterly parent professional partnership meetings?