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Phone Consultation Questionnaire

The Questionnaire that you will receive will be asking for details in several areas. After working with special education students for over 30 years, I have learned that the problem we are looking at is often not the root of the real issue. Think of this questionnaire as an educational "case history" that is much like forms you prepare for your first visit to a medical specialist. You will be asked questions about your child’s educational history, a brief description of any significant medical history, relevant family history, and descriptions of situations where specific problems typically occur. You will not be asked questions that intrude into areas of your personal privacy nor your child’s privacy, but the more information you are able to provide, the easier it becomes to pinpoint possible causes for your difficulty. The more accurately we can diagnose causes, the more precisely we can recommend solutions. ALL information you provide remains totally confidential and we will return your information packet to you along with the Consultation Report.

Educational History Section

You can light the way! 
 You will need to describe the kind of educational placement your child was working in since kindergarten. You will be asked for information about your child’s responses to early academic teaching and to describe any signs of difficulty that appeared.

There will be questions about the kinds of reading and/or math materials your child has used; such information helps in discovering whether or not your child’s problems are related to faulty instructional programs. You may not be able to answer all the questions, but it is important that you be as complete as possible. 
Good schooling
brings joy!

Medical History Section


We need the doctor's help! 
You will be asked basic questions about early illnesses, pregnancy complications and hospitalizations or surgeries. These are standard questions. Recent research has also provided information about certain sets of factors such as exposure to environmental toxins that can seriously affect a child’s educational performance. There will be questions seeking information about these less well-known problem areas. You will also be asked whether your child is currently taking any medications and you will be asked to list them. Again, it is important for you to provide answers as completely as possible.

Family History Section

These questions are not meant to be intrusive, but because the research indicates that some children’s problems can be tied to family genetics, it is important to be as accurate as possible. You will also be asked to explain the nature of your family situation as it relates to being a one-parent or two-parent home, and any significant emotional traumas that may have kept the child’s attention from focusing on academic work for a significant time. This information is often far more significant than many parents realize in understanding the child’s educational performance.
Strong families are a blessing!

Evaluation Section

Assessments are important!

You will be asked to provide COPIES of any formal evaluations or diagnostic tests that have been done for your child. This includes medical evaluations for Attention Deficit or other problems, Intelligence Tests and/or Educational Assessments, such as the Stanford 9, the California Achievement Tests, or similar standardized tests. If possible, you should include copies of teacher comments on report cards and other information that might provide a clearer picture of your child’s educational difficulties.