Date______

Service Provider and Parent Interview

Student ______Service Provider/Parent______

DOB______Interviewer______

Outcome 1 - Positive social-emotional skills

How does the child play or interact with other children?For example, do they play alongside others or initiate play? Do they share and take turns? ______

How does the child interact with familiar and other adults? Is the child able to follow verbal directions, or does the child need prompts and reminders? ______

Describe how you know whatthe child is feeling. Does the child use words to describe how he or she feels or why they feel a certain way? Does the child point out emotions and feelings of others?

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Describe how the child engages with toys and materials in his/her environment.Does the child use materials in appropriate ways?Does the child take care of his belongings, and help out at home or school?

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Describe how the child resolves conflicts. Do they accept a compromise when suggested by adults, seek adult assistance or try to negotiate to reach a compromise?

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Does the child generally follow rules and routines? Please explain.

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Outcome 2-Aquistion and use of knowledge and skills

Describe how the child responds to new situations. Do they observe and interact with curiosity or connect the new situation to past experiences?

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Does the child sort, measure, use words to compare quantities, compare or arrange objects in a series?

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Does the child recognize or create patterns (items that repeat)?

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Does the child have a since of time: past, present and future? Do they talk about what happened in earlier events or what will happen?

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Describe how the child uses counting and numbers. When counting do they point to each item being counted?

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Does the child enjoy pretend and making believe with objects? Please explain.

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Does the child enjoy books and being read to? Do they use pictures or letter knowledge such as recognition or letter sounds to comprehend meaning from books?

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Outcome 3-Use of appropriate behaviors to meet needs

How does the child interact with familiar and other adults? Do they appear to show confidence a caretaker to keep him or her safe? Do they know the difference between familiar adults and strangers?

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Describe how the child dresses him or her self and takes care of routine needs such as hand washing, toileting and brushing teeth.

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Describe how the child useswriting tools, scissors, eating utensils, opens doors, and use hands in dressing such as buttoning, snapping, zipping.

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Describe how the child performs when running, jumping, hopping, galloping and climbing.

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When faced with a challenging task or activity, how does the child react? Do they show persistence or a desire to complete challenging tasks with assistance or independently?

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Describe how the child communicates needs and wants using words or gestures, signs, picture symbols or other types of assistive technology.Does the child ask and answer questions to have needs met or participate in conversation?

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