Cooke Center Grammar School

Lower School
FAMILY QUESTIONNAIRE
Student Name: ______________________________________________________
Parent/Caregiver Name(s): ____________________________________________
Email: _____________________________________________________________
Phone: ____________________________________________________________
Preferred Method of Contact: (Please circle one)

Phone

Email

-------------------------------------------------------------------------------------------------------------

STUDENT INFORMATION
Students Birthday: __________________________________________________
Adults living at home: _______________________________________________
___________________________________________________________________
Meaningful Relationships (siblings, friends, caregivers, etc.):
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Favorite outdoor activities: ____________________________________________
___________________________________________________________________
___________________________________________________________________
Favorite indoor activities: _____________________________________________
___________________________________________________________________
___________________________________________________________________
2014-2015

Please list any extracurricular activities (after-school, weekends, tutoring, clubs):

___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
What types of activities does your child enjoy with the family? _______________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
If your child has an hour of free time, how will he/she most likely use that time?
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
What do you most admire about your child? ______________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
YOUR CHILDS FAVORITE INTERESTS
Sports/Games
TV/Movies
Music/Books
Video/Computer Games/Apps
Topics of Conversation
Places to Visit
2014-2015

Sensory Input
(e.g., activities, movement)
Food/Drinks

What are your childs strengths? ________________________________________

___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
What is challenging for your child? ______________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
What motivates your child? ___________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Is your child new to Cooke?

(Please circle one)

YES

NO

If YES, please tell us about your childs last school:

Where did your child attend school last year? __________________________
Class size? _______________________________________________________
Classroom setting? ________________________________________________
Classroom support? _______________________________________________
Grade level? _____________________________________________________
What three adjectives best describe your child?
___________________

____________________
2014-2015

____________________

MEDICAL HISTORY
Does your child have any significant events in his/her medical history (such as
surgeries, hospitalizations, or regressions)? If yes, please explain.
___________________________________________________________________
___________________________________________________________________
Does your child take any medication? If yes, please include name and purpose.
___________________________________________________________________
___________________________________________________________________
Does your child have asthma? If yes, does he/she use an inhaler during the school day?
___________________________________________________________________
Does your child have seizures? If yes, please describe a typical episode (i.e.,
length of duration, physical appearance, possible triggers). __________________
___________________________________________________________________
___________________________________________________________________
Does your child have allergies? If yes, does he/she take medication or require an
epi pen? ___________________________________________________________
___________________________________________________________________
Does your child have a special or limited diet? _____________________________
___________________________________________________________________
Does your child have hearing aids? ______________________________________
___________________________________________________________________
Does your child have eyeglasses? _______________________________________
Does your child use splints, orthotics, or other medical equipment? ___________
___________________________________________________________________
2014-2015

Is there any other medical information your childs school team should know?
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
-------------------------------------------------------------------------------------------------------------

SPEECH AND LANGUAGE THERAPY

When did your child begin speaking
in words? In sentences?

What are your childs strengths with

speech or language?

What areas of speech or language are

difficult for your child?

What goals would you like your child

to achieve this school year?
What languages does your child
speak?
What languages does your child
understand?
What languages are spoken at home?

2014-2015

Describe the fluency of your childs

speech (e.g., speaks smoothly, some
pauses/breaks, noticeable repetition
of sounds, long breaks between words
and/or sounds).
Describe your childs conversation
skills. Please include a preferred
audience (e.g., adults, peers, self).
Please list conversation situations
that your child may avoid (e.g.,
speaking with unfamiliar adults,
new friends)
Does your child exhibit interest in
certain conversation topics?
If so, what are the topics?
Does your child receive therapy
services outside of school?
If so, may we contact the therapist?
Please provide the therapists contact
information.
Has your childs speech and language
been recently evaluated?
If so, please attach a copy of the most
recent evaluation.
2014-2015

OCCUPATIONAL THERAPY
Please check any items that describe your child.

ADAPTIVE BEHAVIOR/EMOTIONAL SKILLS

Disorganized
Hyperactive
Short attention span
Difficulty with changes in routine
Easily frustrated
Shy with peers or adults
Impulsive
MOTOR SKILLS
Poor posture (leans when standing, hunches at desk, etc.)
Poor body awareness (clumsy, bumps into people/objects, etc.)
Appears stiff and awkward
Difficulty with right/left discrimination
Difficulty with running, hopping, skipping, two-footed jumping, etc.
Avoids activities that challenge balance
Appears weaker than peers; fatigues easily
Difficulty with coloring, drawing, writing, cutting, etc.
Avoids above fine motor activities
Difficulty holding a pencil; grasp may be too tight or very loose
Does not have hand dominance
SENSORY SKILLS
Tactile defensive (dislikes tags, different textures, dislikes bathing/grooming routines)
Touches everything; trouble keeping hands to self
Avoids being close to others
Picky eater; sensitive to certain textures and temperatures
Mouths or licks non-food items
Hypersensitivity to certain sounds
Seeks movement; purposely crashes; enjoys horseplay
Displays evidence of gravitational insecurity (avoids playground equipment or
having feet off the ground, etc.)
2014-2015

VISUAL PERCEPTUAL SKILLS

Frequently confuses letters and shapes (b vs. d, p vs. 9, etc.)
Difficulty copying shapes and forms
Cannot complete puzzles appropriate for age
Loses place when reading
Difficulty maintaining visual attention
Difficulty with hidden pictures; word searches; seeing an object in a cluttered
environment
SELF-CARE SKILLS
Difficulty with snaps, zippers, and/or buttons
Difficulty or unable to tie shoes
Difficulty dressing independently (directionality, organization, management of
clothing, etc.)
Difficulty brushing teeth independently
Difficulty with daily face care and hair care ( combing, grooming, and hygiene)
Difficulty with daily showering/bathing
Difficulty washing and drying hands independently
Difficulty with toileting (clothing management and hygiene)
1. Does your child receive occupational therapy services outside of school (home
care, sensory gym, etc.)? If so, please explain. __________________________
________________________________________________________________
________________________________________________________________
2. Please describe any goals for your childs occupational therapy:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
2014-2015

PHYSICAL THERAPY
Gross Motor Development
1) What types of physical activity does your child enjoy (e.g., playground, balls,
jump-rope, sports, swimming, bike-riding, dancing)? _____________________
________________________________________________________________
________________________________________________________________
2) What types of physical activity does your child enjoy with the family?
________________________________________________________________
________________________________________________________________
3) What type of physical activity did your child do over the summer?
________________________________________________________________
________________________________________________________________
4) Does your child have difficulty with balance, strength, endurance, tightness,
or coordination? (Please list any that apply and explain if possible.)
________________________________________________________________
________________________________________________________________
5) If your child is mandated to receive Physical Therapy, do you have any
particular areas of concern or goals that you would like addressed this year?
________________________________________________________________
________________________________________________________________
6) Is there anything else that would be helpful to know about your childs
physical needs?
________________________________________________________________
________________________________________________________________
2014-2015

COUNSELING
Behavior/Temperament (check all that apply)

Lacks Self-Control
Withholds Affection
Has Fears
Seems Impulsive
Difficulty Calming Down
Uncomfortable With New People
Explain/Other__________________________________________________
Friendships (check all that apply)

Fights Frequently With Playmates

Prefers Playing With Younger Children
Prefers Playing Alone
Explain/Other__________________________________________________
What role does your child take in peer group games (leader, follower, etc)?
_____________________________________________________________
Feelings
Can your child identify feelings and/or express feelings? (Please explain)
__________________________________________________________
Goals
What social-emotional and play-related goals do you have for your child this year?
__________________________________________________________
__________________________________________________________
2014-2015