IEP 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:*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:*FemaleMale Parent/Guardian's Name:* First Last Mailing Address:* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest 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:*PublicPrivateHomePrimary 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PacificDescribe Parent Concerns:* Does the student have a current IEP?*YesNoHas the student had an IEP, but it is no longer active?*YesNoPrimary Exceptionality (reason for special education services) - Select one of the following:*Autism, Pervasive Developmental Disorder (PDD)BlindnessDeafnessDevelopmental delayEmotional disturbanceHearing impairmentIntellectual disability, Dyslexia, Perceptual disabilityMultiple disabilitiesOrthopedic impairmentOther health impairmentSpecific learning disabilitySpeech or language impairmentTraumatic brain injuryVisual impairment, including blindnessOther health impaired (OHI) Attention Deficit Disorder (ADD) Attention Hyperactive Deficit Disorder (ADHD), Brain injury, Cancer, Cerebral Palsy, Touretts Syndrome, EpilepsySecondary Exceptionality (optional) - Select one of the following:Autism, Pervasive Developmental Disorder (PDD)BlindnessDeafnessDevelopmental delayEmotional disturbanceHearing impairmentIntellectual disability, Dyslexia, Perceptual disabilityMultiple disabilitiesOrthopedic impairmentOther health impairmentSpecific learning disabilitySpeech or language impairmentTraumatic brain injuryVisual impairment, including blindnessOther 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?*YesNoIn 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?*YesNoDon't KnowCan the student follow oral or written directions from an adult?*YesNoDon't KnowDoes the student need directions repeated frequently?*YesNoDon't KnowDoes the student make use of assistive technology or devices?*YesNoDon't KnowList 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?*YesNoDon't KnowPlease explain:*Does the student have a math disability?*YesNoDon't KnowPlease explain:*Does the student have a writing disability?*YesNoDon't KnowPlease explain:*Does the student have Asperger?*YesNoDon't KnowPlease explain:*Does the student have ADD/ADHD?*YesNoDon't KnowPlease explain:*Does the student have Autism?*YesNoDon't KnowPlease explain:*Does the student have any other disability?*YesNoDon't KnowPlease explain:* Is the student distracted easily?*YesNoDon't KnowPlease explain:*Does the student exhibit behaviors that may disrupt the attention of other students or themselves?*YesNoDon't KnowPlease explain:*Do any academic accommodations need to be made for the student in the classroom (computers, calculators, extra time, etc.)?*YesNoDon't KnowPlease explain:*Can the student work continuously for the length of time allocated for testing, classwork, or homework?*YesNoDon't KnowPlease explain:*Does the student take any type of medication to facilitate optimal performance?*YesNo Is the student able to read and understand directions?*YesNoCan the student follow oral directions?*YesNoDoes the student have trouble completing homework?*YesNoDon't KnowPlease explain:*Does the student misunderstand social cues?*YesNoDon't KnowPlease explain:*Does homework create too much stress in the family?*YesNoDon't KnowPlease explain:* List private therapies used:*List hobbies and interests:*Is there a history of behavior problems?*YesNoDon't KnowPlease 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?*YesNoDon't KnowPlease explain:*Is attendance at school a problem?*YesNoDon't KnowPlease explain:*Please describe student's behavior in or out of school:*Does the student have difficulty working independently?*YesNoDon't KnowPlease explain:*Additional Comments:NameThis field is for validation purposes and should be left unchanged. Contact us now to see how RESOURCE Education Solutions can help your student succeed. 404-396-6063 in the Atlanta area mail4kaplan@gmail.com