ELEANOR VAN GELDER SCHOOL
INTERVENTION AND REFERRAL SERVICES
Confidential
PARENT QUESTIONNAIRE
Student’s Name: ______
Parent’s Name: ______
Date: ______
1) What do you see as your child’s strengths?______
______
2) What makes you proud of your child?______
______
3) What does your child do that causes you the most concern?______
______
4) What has been the most successful way to deal with your child’s behavior? ______
______
5) How can the school assist you with the concerns you have for your child or the
concerns that have been identified by the school? ______
______
6) In the past school year, has your child been seen by a doctor for anything other than a
common illness? If so, what caused you to take your child to the doctor? ______
______
7) Has your child been seen by a health professional for any physical or emotional
problem that interfered with your child’s success in school? ______
______
8) What other information about your child or your family situation would be helpful for
the school to know?______
______
9) Does anyone in the family have a history of similar concerns? ______
______
Please use the following rating scale to answer the questions below:
Always (4) Most of the Time (3) Hardly Ever (2) Never (1)
______1) Finishes what she/he begins.
______2) Does the things I ask her/him to do.
______3) Appears content.
______4) Gets along with her/his friends.
______5) Takes good care of her/his things.
______6) Helps at home.
______7) Makes me proud.
______8) Shares.
______9) Cries easily.
______10) Talks back.
______11) Hits.
______12) Lies
______13) Appears afraid.
______14) Must be reminded to do things.
______15) Gets hurt often.
______16) Feels sick often.
______17) Fights.
______18) Ruins things.
______19) Teases others frequently.
______20) Threatens others.
______21) Has trouble remembering things.
______22) Accepts criticism.
______23) I trust my child
______24) I know what to expect from my child.
Please return the completed questionnaire to the following address:
Eleanor Van Gelder School
251 Undercliff Avenue
Edgewater, NJ 07020
Attn: Marissa Fleming