Oliver Mercer Special Education

OLIVER MERCER SPECIAL EDUCATION

Parent Documentation

For Consideration of an Emotional Disability

Dear Parent:

The educational term “Serious Emotionally Disturbed” is defined as follows: A condition exhibiting one or more of the following characteristics over a long period of time (6 months) and to a marked degree which adversely affects educational performance.

1. An inability to learn which cannot be explained by intellectual, sensory, or health factors.

2. An inability to build and maintain satisfactory interpersonal relationships with peers and teachers.

3. Inappropriate types of behaviors or feelings under normal circumstances.

4. A general pervasive mood of unhappiness or depression, or

5. A tendency to develop physical symptoms or fears associated with personal or school problems.

Please complete the enclosed questionnaire. This will become part of the documentation to help the

multi-disciplinary team of which you are a decision-making member.

Please return the information to:

Name: Principal

Address:

Phone:

Parent Questionnaire for Emotional Disability

1. Inability to learn which cannot be explained by intellect, sensory, or health factors.

A. Does your child routinely complete homework? ______Yes ______No

1. How long does he/she spend each evening? ______Minutes ______Hours

B. Is there a specific designated time for completing homework? ______Yes ______No If yes, when:

______

C. Does your family have any history of mental illness? ______Yes ______No If yes, explain: _____

______

D. Does your child have a history of medical problems? ______Yes ______No If yes, explain: _____

______

E. Have there been any life changes the past six months for your child? ______Yes ______No

______Family death______Divorce______Crime______Serious Illness

______Other (Explain) ______

2. Difficulty building or maintaining satisfactory interpersonal relationships with peers/adults?

A. Does your child have an individual or group of friends he regularly associates with outside of school?

______Yes ______No

B. Do you have power struggles with your child to complete chores? ______Yes ______No If yes,

explain: ______

______

C. Do you believe that your child is excessively dependent on you to handle normal age appropriate decisions? ______Yes ______No If yes, explain; ______

______

D. Can your child maintain positive relationships with brothers and sisters (if applicable)? ______Yes

______No ______Number of siblings If no, explain: ______

______

E. Does your child interact with you and your spouse in a satisfactory manner? _____Yes ______No

If no, which adult does your child routinely avoid? ______Mother ______Father

3. Inappropriate behaviors/feelings under normal circumstances.

A. Is your child cruel to siblings and/or pets? ______Yes ______No If yes, explain: -______

______

B. Does your child have to be the center of attention? ______Yes ______No If yes explain: ______

______

C. Have you observed continuous lying and/or stealing? ______Yes ______No If yes, explain: ___

______

D. Have you had problems with physical threats to self and/or others? ______Yes ______No If yes,

explain: ______

E. Has your child been destructive to property or people when angry? ______Yes ______No If yes,

explain: ______

4. General pervasive mood of happiness and/or depression.

A. Has your child contemplated suicide? ______Yes ______No If yes, explain: ______

______

B. Does your child routinely avoid being around family? ______Yes ______No If yes, explain: ___

______

C. Does your child have a normal sleep pattern? ______Yes ______No If yes, explain: ______

______

D. Does your child have a wide range of varied mood swings? ______Yes ______No If yes, explain:

______

E. Does your child excessively personalize in a negative way? (always blaming others)? ______Yes

______No If yes, explain: ______

______

5. A tendency to develop physical symptoms/fears associated with school problems.

A. Is your child continuously complaining that he/she is sick? ______Yes ______No If yes, explain:

______

B. Does your child consistently take common over-the-counter drugs? ______Yes ______No If yes,

what types? ______

C. Does your child consistently skip meals and/or eat very little or excessively? ______Yes ______No

If yes, how long has this been occurring? ______

D. Does your child have a severe/bizarre fear of an object, person, or event? ______Yes ______No

If yes, explain: ______

E. Do you struggle getting your child up and ready for school each day? ______Yes ______No If yes,

explain: ______

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