504 Plan Questionnaire

So we can do our best to help you please answer the questions below. Your accuracy is important for our success. During the in-person consultation we will discover more information that will allow us to provide the best service we can.
Student's Name:*
First Last
Student's Age:*
Please enter a number from 1 to 21.
Date of Birth:*
Date Format: MM slash DD slash YYYY
Grade:*
Gender:*
- Female
- Male

Parent/Guardian's Name:*
First Last
Mailing Address:*
Street Address Address Line 2 City State ZIP Code
Parent/Guardian's Email:*
Enter Email Confirm Email
Parent/Guardian's Primary Contact Phone:*

Name of School Enrollment:*
Type of School:*
- Public
- Private
- Home
Primary School Phone Number:*
School District:*
State in which Student is Educated:*
Describe Parent Concerns:*

Does the student have a current 504 plan?*
- Yes
- No
Has the student had an 504 plan, but it is no longer active?*
- Yes
- No
Primary Exceptionality (reason for special education services) - Select one of the following:*
- ‏Autism, Pervasive Developmental Disorder (PDD)
- Blindness
- Deafness
- ‏Developmental delay
- Emotional disturbance
- Hearing impairment
- ‏Intellectual disability, Dyslexia, Perceptual disability
- Multiple disabilities
- ‏Orthopedic impairment
- ‏Other health impairment
- ‏Specific learning disability
- ‏Speech or language impairment
- ‏Traumatic brain injury
- ‏Visual impairment, including blindness
- ‏Other health impaired (OHI) Attention Deficit Disorder (ADD) Attention Hyperactive Deficit Disorder (ADHD), Brain injury, Cancer, ‏Cerebral Palsy, Touretts Syndrome, Epilepsy
Secondary Exceptionality (optional) - Select one of the following:
- ‏Autism, Pervasive Developmental Disorder (PDD)
- Blindness
- Deafness
- ‏Developmental delay
- Emotional disturbance
- Hearing impairment
- ‏Intellectual disability, Dyslexia, Perceptual disability
- Multiple disabilities
- ‏Orthopedic impairment
- ‏Other health impairment
- ‏Specific learning disability
- ‏Speech or language impairment
- ‏Traumatic brain injury
- ‏Visual impairment, including blindness
- ‏Other health impaired (OHI) Attention Deficit Disorder (ADD) Attention Hyperactive Deficit Disorder (ADHD), Brain injury, Cancer, ‏Cerebral Palsy, Touretts Syndrome, Epilepsy

Has the student been retained in any grade?*
- Yes
- No
In which grades and for what reasons was the student retained?*
Student's Current Grades:
Please list all subjects and the grade for each subject. Use the + symbol to add additional entries.*
Subject Grade

Is the student able to read with understanding?*
- Yes
- No
- Don't Know
Can the student follow oral or written directions from an adult?*
- Yes
- No
- Don't Know
Does the student need directions repeated frequently?*
- Yes
- No
- Don't Know
Does the student make use of assistive technology or devices?*
- Yes
- No
- Don't Know
List any assistive hardware used:*
List any assistive software used:*
Describe how technology improves the student's academic performance in school or at home:*

Does the student have a reading disability?*
- Yes
- No
- Don't Know
Please explain:*
Does the student have a math disability?*
- Yes
- No
- Don't Know
Please explain:*
Does the student have a writing disability?*
- Yes
- No
- Don't Know
Please explain:*
Does the student have Asperger?*
- Yes
- No
- Don't Know
Please explain:*
Does the student have ADD/ADHD?*
- Yes
- No
- Don't Know
Please explain:*
Does the student have Autism?*
- Yes
- No
- Don't Know
Please explain:*
Does the student have any other disability?*
- Yes
- No
- Don't Know
Please explain:*

Is the student distracted easily?*
- Yes
- No
- Don't Know
Please explain:*
‏Does the student exhibit behaviors that may disrupt the attention of other students or themselves?*
- Yes
- No
- Don't Know
Please explain:*
‏Do any academic accommodations need to be made for the student in the classroom (computers, calculators, extra time, etc.)?*
- Yes
- No
- Don't Know
Please explain:*
Can the student work continuously for the length of time allocated for testing, classwork, or homework?*
- Yes
- No
- Don't Know
Please explain:*
Does the student take any type of medication to facilitate optimal performance?*
- Yes
- No

‏Is the student able to read and understand directions?*
- Yes
- No
Can the student follow oral directions?*
- Yes
- No
‏Does the student have trouble completing homework?*
- Yes
- No
- Don't Know
Please explain:*
‏Does the student misunderstand social cues?*
- Yes
- No
- Don't Know
Please explain:*
‏Does homework create too much stress in the family?*
- Yes
- No
- Don't Know
Please explain:*

List private therapies used:*
List hobbies and interests:*
‏Is there a history of behavior problems?*
- Yes
- No
- Don't Know
Please explain:*
‏List interventions, accommodations, or modifications, used at school or at home that were successful or that did not help:*

‏Is the student making progress in the general education curriculum?*
- Yes
- No
- Don't Know
Please explain:*
Is attendance at school a problem?*
- Yes
- No
- Don't Know
Please explain:*
Please describe student's behavior in or out of school:*
Does the student have difficulty working independently?*
- Yes
- No
- Don't Know
Please explain:*
Additional Comments:
Phone
This field is for validation purposes and should be left unchanged.

Contact us now to see how

RESOURCE Education Solutions

can help your student succeed.

404-256-5500 in the Atlanta area

mail4kaplan@gmail.com

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Name*
First Last
Email*
Enter Email Confirm Email

Subject	Grade

Student's Current Grades:

Contact us now to see how

RESOURCE Education Solutions

can help your student succeed.

404-256-5500 in the Atlanta area