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Nahomi Rosas School Psychologist

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Parent Questionnaire
Teacher Questionnaire

Teacher Questionnaire

Please complete this questionnaire to the best of your ability related to the student. Thank you

Thank you for your response. ✨

Teacher Name(required)

Student Name(required)

READING

Decoding

Below Average Average Above Average

Fluency

Below Average Average Above Average

Comprehension

Below Average Average Above Average

Suggestions for academic improvements/goals:

Writing

Below Average Average Above Average

Suggestions for academic improvements/goals:

Math

Number Sense

Below Average Average Above Average

Problem Solving

Below Average Average Above Average

Suggestions for academic improvements/goals:

How does the student behave in your class (e.g., Citizenship) ?

Academic

Uses class time efficiently

Almost always Sometimes Never

Works independently

Almost always Sometimes Never

Requires adult supervision to initiate work

Almost always Sometimes Never

Personal/Social/Behavior

Cooperates with adult (generally)

Almost always Sometimes Never N/A

Interacts well with peers

Almost always Sometimes Never N/A

Follows classroom/school rules

Almost always Sometimes Never N/A

Accepts responsibility for behavior

Almost always Sometimes Never N/A

Responds well to praise

Almost always Sometimes Never N/A

Must be constantly supervised or directed

Almost always Sometimes Never N/A

Seems withdrawn preoccupied

Almost always Sometimes Never N/A

Defiant

Almost always Sometimes Never N/A

Communicates and responds to peers appropriately

Almost always Sometimes Never N/A

Misunderstands behavior consequences

Almost always Sometimes Never N/A

Demonstrates skill in resolving conflict peacefully

Almost always Sometimes Never N/A

Please use the following scales to complete these sections: Not Observed- behavior not observed in this child Mild- Behavior occasionally observed in this child Severe- Behavior almost always observed in this child

Visuospatial Processes

Shows right-left confusion or confusion with directions (up-down)

Severe Mild Not observed

Difficulties with putting puzzles together

Severe Mild Not observed

Auditory processes

Difficulty with sound discrimination

Severe Mild Not observed

Difficulty with blending of sounds to form words

Severe Mild Not observed

Omits sounds when reading or speaking

Severe Mild Not observed

Learning and Memory Processes

Difficulty learning new verbal information

Severe Mild Not observed

Difficulty learning new visual information

Severe Mild Not observed

Difficulty integrating verbal and visual information

Severe Mild Not observed

Forgets where personal items or school work were left

Severe Mild Not observed

Limited knowledge of basic facts for places, events and people

Severe Mild Not observed

Reasoning Processes

Quickly becomes frustrated and gives up easily

Severe Mild Not observed

Difficulty figuring out how to start a complex task

Severe Mild Not observed

Difficulty solving problems that she recently learned

Severe Mild Not observed

Makes the same kinds of errors over and over, even after corrections

Severe Mild Not observed

Attention/working memory processes

Seems to get overwhelmed with difficult tasks

Severe Mild Not observed

Difficulty paying attention for a long period of time

Severe Mild Not observed

Seems to lose place in an academic task (e.g. reading, writing, math)

Severe Mild Not observed

Frequently asks for repetitions of instructions

Severe Mild Not observed

Trouble following multiple step directions

Severe Mild Not observed

Speed,Fluency, and Efficiency of Cognitive Processing

Takes longer to complete tasks than others the same age

Severe Mild Not observed

Requires extra time to complete tests

Severe Mild Not observed

Does not do well on timed tests

Severe Mild Not observed

Difficulty recalling information accurately and quickly

Severe Mild Not observed

Slow and deliberate reader

Severe Mild Not observed

Maintains a clear and sustained focus on the main writing topic

Severe Mild Not observed

Difficulty pulling basic math facts out of memory quickly

Severe Mild Not observed

Additional information: Please complete the following section as thoroughly as possible, include dates if necessary. List 3 Student strenghts:

Thank you for taking the time to complete this document.

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