Date of Birth: / / Teacher Grade

PARENT VIEWPOINT

Student’s Name:

Date of Birth: / / Teacher Grade

Year mo da

In order to provide a program which meets the individual needs, strengths, and

Interests of your child, it is important for us to have any background information

and insights that you are able to provide.

Please feel assured that all information will be treated as confidential, will be

kept in your child’s file and will be used by staff in the best interests of your

child.

GENERAL INFORMATION

List your child’s special strengths, abilities and interests.

List any concerns, fears, dislikes or anxieties your child may have.

SCHOOL

What is the most important area of growth you wish for your child this year?

In what way(s) are you able to support your child at home? (developing study

habits, homework time, daily home reading, etc.)

Do you have any other information you wish to share with us about your child?

HEALTH/MEDICAL

Please identify any health concerns or medical conditions that your child has.

Describe the impact of limitations these health concerns may have on

participation in school activities. List any medications or treatments that are/may

be required.

SOCIAL SKILLS/BEHAVIOUR

Describe how your child interacts with peers, siblings, and adults.

Do you have any concerns about your child’s social skills?

Name of person filling out this form:

Relationship to child (mother, father, foster parent, etc.)

Date: E-mail Address: ______