Name
*
First Name
Last Name
Student Name
*
First Name
Last Name
Email Address
*
Cell
*
(###)
###
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Relationship to Student
Mother
Father
Grandparent
Aunt/Uncle
Other
If Other, please detail below.
What is your current marital status?
If your child is not currently living with his/her biological parents, please give us more detail below. When did the separation occur? To your knowledge, how did the child cope with the event?
If applicable, please let us know of any significant death / illness events in the family.
If applicable, please let us know of any history of mental illness / substance abuse in the family.
Please describe the child's educational history, including any learning disabilities.
Who is the child's primary disciplinarian in the family?
Self
Wife/Husband
Stepmom/Stepdad
Aunt/Uncle
Grandparent
Other
From your experience, what type of guidance or motivation works best for your child?
Has the child ever taken psychiatric medication prescribed for mental health, learning disability, or other reasons?
Yes
No
If Yes, please detail below.
To your knowledge, what are the biggest obstacles to your child's academic success?
Which of the following places have you observed your child completing homework?
If Other, please detail below.
In what setting is your child the happiest?
Please feel free to give us any further details regarding your child or his/her family and home environment here.
