Home
Programs
Why It Works
Why It Works
Research
How We’ve Helped
Articles
About Us
About Us
Contact Us
Student Login
Select Page
Questionnaire
Directions
Mark each statement that applies to your child (even if only sometimes).
Not self-motivated - difficulty working independently
Yes
No
Loses place when reading
Yes
No
Bumps into people and things frequently - loses balance
Yes
No
Difficulty remembering 2 or 3 instructions
Yes
No
Picky about clothes, foods, noise
Yes
No
Difficulty putting story parts in order - what happened first, second, third
Yes
No
Assignments/chores take a long time to complete
Yes
No
Guesses words when reading
Yes
No
Gives up easily - doesn’t give things his/her ‘best effort’
Yes
No
Frequently says “What?” and often asks to have things repeated
Yes
No
Repeats information over and over to remember it
Yes
No
Slumps, sits on leg, or lays on table when working
Yes
No
Difficulty remembering words that have been previously mastered
Yes
No
Has difficulty hearing in a noisy classroom
Yes
No
Has difficulty throwing and/or catching a ball or learning to ride a bike
Yes
No
Misunderstands instructions - does something different than was asked (not out of defiance)
Yes
No
Difficulty staying focused to complete a learning task
Yes
No
Difficulty describing ‘What happened’
Yes
No
You often remind him/her to “Look at me when I’m talking.”
Yes
No
Difficulty organizing ideas when telling (or writing) a story - goes ‘on and on’ but has difficulty getting ‘to the point of the story’
Yes
No
Difficulty estimating the amount of time needed for completing assignments - rushes to finish
Yes
No
Difficulty turning off the television, computer, or other electronics with screens
Yes
No
Loses train of thought if interrupted
Yes
No
Difficulty remembering the spelling of a word to write it down if heard aloud or while copying from the white board - needs spelling repeated or looks up at the board several times to write it down
Yes
No
Difficulty remembering to do all the parts of multi-step assignments
Yes
No
Says (or believes) things like “I’m dumb”, I’ll never ‘get’ it, ….
Yes
No
Difficulty paying attention to ‘boring’ things BUT having good attention for things that are interesting
Yes
No
Does poorly on a test after studying hard and feeling well prepared
Yes
No
Has difficulty staying seated for homework, dinner time, etc.
Yes
No
Easily overwhelmed and frustrated by homework, schoolwork, or learning something new
Yes
No
Can remember lines from movies, songs, etc. and likes to repeat them
Yes
No
Difficulty remembering facts when having to use or combine new information - like getting confused solving math problems where s/he must remember a math fact as well as the order of the steps to solving the problem
Yes
No
Blurts out answers
Yes
No
Skips words, substitutes words, adds words when reading
Yes
No
Difficulty organizing things like desk, backpack, toys
Yes
No
Difficulty getting started on homework, chores, etc.
Yes
No
Misses comprehension questions
Yes
No
Difficulty finding belongings - loses things
Yes
No
Has difficulty forming letters and spacing them when writing
Yes
No
Behind grade level
Yes
No
Child First & Last Name
Relationship to the child
Parent
Guardian
Family
Other
Child Grade Level
Agree to our
Terms of Use
*
Agree to our
Privacy Policy
*
Parent/Guardian First & Last Name
Email
Phone Number
Time is Up!
Time's up
Learn More
Why It Works
Research
How We’ve Helped
Experience Our Programs