Child Intake Form (Page 4 of 4) in pdf

Child Intake Form Page 4

Does your child’s teacher describe any of the following as significant classroom problems:

Doesn’t sit still in his/her seat__________________________________________________________________

Frequently gets up and walks around the classroom___________________________________________

Shouts out. Doesn’t wait to be called on_____________________________________________________

Won’t wait his/her turn_______________________________________________________________________

Doesn’t cooperate well in group activities____________________________________________________

Typically does better in a one-to-one relationship______________________________________________

Doesn’t respect the rights of others___________________________________________________________

Doesn’t pay attention during storytelling or show and tell______________________________________

ADDITIONAL REMARKS

Please use this space to make any additional remarks you wish regarding your child

Child Intake Form Page 4