270 Farmington Avenue
Suite #344
Farmington, CT 06032
/ Joseph F. Kulas, Ph.D., ABPP
Board Certified Clinical Neuropsychologist /
Phone: (203) 805 - 8527
Fax: (203) 271-2320

MIDDLE AND SECONDARY SCHOOL QUESTIONNAIRE

Student's name: ______BD: ______

Name of school: ______Phone: ______

Address of school: ______

Present grade: ______

Is this student frequently absent/tardy? YesNo

Is this student receiving special services? YesNo (If “no”, go to II)

I. SPECIAL SERVICES

A. Educational setting:

residential

Name of facility: ______

Address: ______

self-contained with no mainstreaming

resource room

special education within the mainstream class

tutorial intervention

title intervention

speech and language

OT/PT

adaptive physical education

other (please specify)

  1. Educational Exceptionality:

Intellectual Disability(MR)Multiply-handicapped

Emotional Disturbance(SED)Non-categorical

LDOther Health Impaired (ADHD)

SpeechNeurologically Impaired

LanguageAutism

Hearing ImpairedVisually Impaired

Traumatic Brain Injury

  1. Intervention (please specify):

1. Area of intervention: ______

Frequency: ______Class size: ______

2. Area of intervention:

Frequency: ______Class size: ______

3. Area of intervention:

Frequency: ______Class size: ______

4. Are special modifications necessary in the regular classroom? If so, please give a brief description.

______

II. FORMAL EVALUATIONS (testing)

Please provides dates of last assessments:

Date of Evaluation / Type of evaluation
Educational/Academic
Psychological (cognitive and personality) evaluation
Speech and language assessment
Occupational therapy evaluation
Physical therapy evaluation
Other:

Please enclose copies of all above mentioned testing completed on this student.

III. TEACHER OBSERVATIONS

  1. Is this student performing at or above grade level in the following areas:

Language ArtsYesNo

Social Studies YesNo

SpellingYesNo

ScienceYesNo

MathematicsYesNo

Foreign LanguageYesNo

Computer LiteracyYesNo

VocationalYesNo

Additional comments: ______

______

______

  1. Is this student’s rate of progress consistent over time? YesNo

If no, please explain ______

______

  1. What are seen as the reasons for this student’s problems in school?

______

______

______

______

  1. When did the problems at school first manifest themselves?

______

______

______

______

  1. Whether or not the school is the referring agent, we would like to know what questions you would like answered or what issues resolved through this evaluation.

______

______

______

IV. SPEECH AND LANGUAGE HISTORY

  1. Is English this student's primary language? ______
  1. What language does this student use in the home?______

at school? ______

  1. Do you feel this student has any other problems that affect his/her speech or language?

______

  1. Describe any physical handicaps this student has that may interfere with speaking. ______

______

______

______

  1. Is this student easily understood by family members?______

non-family members? ______

  1. Have there been any recent changes (increase or decrease) in the way this student communicates, e.g., sounds, words, understanding?

YesNo If so, please describe:

______

______

______

______

  1. HEARING:

1. Are there concerns about this student's hearing? YesNo

2. Does this student look at the speaker's face? YesNo

  1. STUDY AND ORGANIZATIONAL SKILLS:
  1. Does student come to class prepared? ______

______

______

______

  1. Do you have concerns regarding the student’s ability to take notes

within the classroom setting? ______

______

______

______

3. Do you have concerns regarding the student’s homework completion (e.g. late or incomplete assignments, forgotten or uncompleted assignments, excessive time needed to complete assignments)?

______

______

4. Do you have concerns regarding student’s timely completion of long term assignments? ______

______

______

______

VII. SOCIAL/EMOTIONAL/BEHAVIORAL FUNCTIONING

  1. Do you have any concerns regarding inattention, distractibility, and/or level of activity? ______

______

______

  1. Do you have any concerns regarding behavior (withdrawn, oppositional or aggressive behavior or substance abuse)? ______

______

______

______

  1. Do you have any concerns regarding atypical or unusual behaviors (perseveration, inconsistent eye contact, stereotypic movement)?

______

______

______

  1. How does this student relate to his/her peer group? Please comment.

______

______

______

  1. What behavioral interventions have been tried with the student? What attempts have been made to involve the family?

______

______

______

  1. What has been the outcome of these interventions to date?

______

______

  1. Are there any other concerns/comments you wish to mention?______

______

______

Completed by:

______

NameTelephone

______

Position/TitleDate

______

NameTelephone

______

Position/TitleDate

______

NameTelephone

______

Position/TitleDate