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Parent Questionnaire

Please complete this form before your child's first assessment appointment. You will be emailed a copy of your responses.

Please contact us at (615) 739-0547 if you are unable to fill out this form online.

Contact Information

Date

(mm/dd/yyyy)

Child's Name

First Name

Last Name

Child's Date of Birth

(mm/dd/yyyy)

Completed by:

Parent Mobile

Parent Email

Verify Email

Student's Current School

Current Grade

Please describe your most immediate academic concerns for your child.

Please describe your child's strengths as a learner.

Has your child had any previous testing?

YES

Are you able to provide a copy to us?

If yes, you can upload the file here or bring a copy to your child's appointment.

File Upload

Please describe your child's attention both at home and at school.

Does your child have a family history of Dyslexia, special education, speech problems, behavioral problems, or other learning disabilities?

Do you have any concern(s) regarding your child's speech and language development?

Is your child aware of, or frustrated by, any speech and/or language difficulties?

Please list your child's siblings names and ages

Please list the adults names and relationship to the child that you child lives with.

What languages are spoken in the home?

Did your child have any newborn/infant problems?

Did your child experience typical motor development?

Did you child experience typical language development?

Please list the schools that your child has attended and for which grades

Please describe any notable positive or negative experiences that your child has had in school.