English Questionnaire

Parent or Guardian's Name *

First Name

Last Name

Child's Name *

First Name

Last Name

Does your child has a primary diagnosis? *

(ADD, ADHD, ASD, speech-language, learning disability, etc)

Yes

No

What do you expect from this binder for your child? *

Choose all that apply

Fun

Learning

Additional Help at Home

Help for specific topic from school as an extra practice

Home activities to reinforce speech-language and/or occupational therapy

Other

Does the child has adequate attention span? *

Yes

No

Can pay attention and follow simple commands?("come here, sit down, etc.") *

Yes

No

Can participate and complete structured activities? (puzzles, reading a book, etc.) *

Yes

No

Is he/she able to complete sequences (brushing teeth, wash hands, etc.)? *

Yes

No

Is he/she able to use pincer grasp (thumb and index finger grasp)? *

Yes

No

Is he/she able to use adequate pencil grasp? *

Yes

No

Establishes eye contact? *

Yes

No

Understands stories when read? *

Yes

No

Imitates or uses speech sounds (ma, pa, ta, etc.)? *

Yes

No

Imitates and/or uses environmental sounds and/or exclamations (mooo, beep, uh-oh, etc.)? *

Yes

No

Uses words to label and for pragmatic functions (requesting, rejecting, etc.)? *

Yes

No

Identifies and understands prepositions (under, in, out, on, etc.)? *

Yes

No

Has awareness of time (today, before, after, etc.)? *

Yes

No

Can trace lines? *

Yes

No

Match objects by shape or color? (puzzles, sorting, etc.)16 *

Yes

No