jeanettespires.com | Parent Brainstorming Form and Questionnaire

Parent Brainstorming Form and Questionnaire

Name*
FirstLast
Name of Student
Email*
Common ground is critical when you are making a change in your child’s life. Please discuss and return with areas of agreement and disagreement that will enable me to help you set priorities. You may fax this to 847-234-7227, or mail to me at 111 Fallstone, Lake Forest 60045.
Areas of common concern in order of priority: Could include respect for authority, addictive behaviors, anger management (verbal or physical), isolation, school performance, etc. *
For each of the above, indicate what you have attempted in order to diminish the behaviors, and how well it has worked: *
Areas of disagreement:
Often a couple’s areas of disagreement come from the methods they have used in attempting to correct behaviors. These areas of disagreement often create a power play for the child, who can use your own behaviors against you in trying to divide and conquer.
Please describe any major ways in which this may be operating in your own situation. *
In what ways has individual counseling helped, or been ineffective? *
Anything else you think we have to know which may not be a part of the referral record:
PARENT QUESTIONNAIRE
Student Name: *
FirstLast
Student DOB*
MM
DD
YYYY
Parent Name: *
PrefixFirstLastSuffix
Day Phone*
Your impressions of what helps your student go forward provide the most important information to help in matching the student to an educational model. Please answer rthe following, which will help us to incorporate your ideas into our comments when screening schools and programs.
Who has been the most influential person outside the family for whom your student performs in a positive way? What was this person like?
What does appear to motivate him or her? (Social acceptance, teacher approval, freedom from outside controls, etc)
What kind of student was this child in early elementary school? Did any difficulties show up in school that surprised you as a parent who knows your child best?
How does this student relate to friends? (leader, follower, changes friends often, few friends, etc. Are there any long-standing relationships?
What talents do you see in this student which make you think of a future career?
How is this student's planning ability? How good is his or her independent timemanagement? How much help is needed in scheduling to meet deadlines?
Has religious training been a part of his or her upbringing? (i.e. church or temple youth groups, service to others, etc.)
If you could design an ideal school for your particular student, what would it be like?
Please note any other information which you think is relevant: If you have behavioral concerns, it is often helpful to both you and me for you to prioritize them in order of importance.

Parent Brainstorming Form and Questionnaire

Areas of disagreement:

PARENT QUESTIONNAIRE