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Your Child Through Your Eyes
This is an intake survey to learn more about your child before the school year begins. If you are interested in having an intake conference to discuss specific concerns or situations, please contact me when school begins to schedule a time.
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Child's Name
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Your answer
Names of Parents/Guardians
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Your answer
Preferred E-mail Address
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Your answer
Primary and/or other language spoken at home
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Your answer
List 3 words that describe your child
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Your answer
What motivates your child?
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Your answer
What upsets your child?
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Your answer
What activities does your child enjoy being involved in outside of school?
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Your answer
What do you and your child enjoy doing together?
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Your answer
Describe the learning environment in which your child does his/her best work
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Your answer
What are your child’s strengths in school?
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Your answer
In what areas do you feel your child could improve?
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Your answer
What goals would you like to see your child accomplish this year?
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Your answer
Briefly describe any allergies/health concerns your child may have. (Note: Be sure to share this information with the school nurse as well.)
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If you are uncomfortable writing them, we can conference about them at a later time.
Your answer
Indicate any significant experiences/family concerns you feel may impact your child (i.e. a serious illness, loss, relocation)
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If you are uncomfortable writing them, we can conference about them at a later time.
Your answer
Please use below if you have any further comments, concerns, or questions.
Your answer
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