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:* MM slash DD slash YYYY Grade:*K - Kindergarden1 - First Grade2 - Second Grade3 - Third Grade4 - Fourth Grade5 - Fifth Grade6 - Sixth Grade7 - Seventh Grade8 - Eighth Grade9 - Ninth Grade10 - Tenth Grade11 - Eleventh Grade12 - Twelfth GradeGender:* Female Male Parent/Guardian's Name:* First Last Mailing Address:* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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:*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificDescribe Parent Concerns:* Does the student have a current 504 plan?* Yes No Has the student had an 504 plan, but it is no longer active?* Yes No Primary Exceptionality (reason for special education services) - Select one of the following:* Autism, Pervasive Developmental Disorder (PDD)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.*SubjectGrade 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:CommentsThis field is for validation purposes and should be left unchanged. Δ Contact us now to see how RESOURCE Education Solutions can help your student succeed. 404-396-6063 in the Atlanta area mail4kaplan@gmail.com