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Learning Style and Background Questionnaire
The following questions are designed to help your coach better understand the best way to work and connect with your child. Please include as much detail as you like.
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Parents Name
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Your answer
Parent/Guardian Phone Number:
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Your answer
Parent/Guardian email:
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Your answer
How did you hear about us?
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Online search
Facebook ad or post
Referred by a friend Shannon
Workshop
Other:
If Facebook, which group or post?
Your answer
Child's Full Name:
*
Your answer
Child's Age:
*
Your answer
Child's Grade:
*
Your answer
Has your child been diagnosed with or labeled as any of the following?
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ADD/ADHD
Anxiety
Autism Spectrum
Speech/Language Delay
Dyslexia/Reading Problem
Auditory Processing Disorder
Other:
Required
What are your main concerns about your child?
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Your answer
When did you first notice this difficulty and who brought it to your attention?
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Your answer
What goals do you have for your child in this program?
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Your answer
What are some of your child’s strengths/talents?
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Your answer
Please list any and all problem areas for your child (ex: reading, spelling, comprehension, listening, etc.).
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Your answer
How does your child feel about his/her success as a student?
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Your answer
How would you describe your child’s learning style? For example, some learn best by listening, seeing, moving, or a combination of these.
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Your answer
Is there anything, in particular, your child is really interested in or motivated by?
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Your answer
Describe the ideal teacher for your child. Alternatively, describe the best teacher your child has ever had. What did that teacher do or not do that was so beneficial for your child? Please be as detailed as possible.
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Your answer
What teaching style does your child learn best with? For example, some children need a teacher who is more firm and strict, and others benefit from receiving lots of positive reinforcement and affirmations.
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Your answer
Please share anything else you think may be important for us to know or keep in mind when working with your child.
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Your answer
What is your child's availability for sessions? Include days and timeframes in CT. What is your desired schedule? We will do our best to accommodate this.
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Your answer
What is your desired number of sessions per week?
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2
3
4
5
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