Phone Number of Parent Completing This Form

Email Address of Parent Completing This Form

Describe your child's relationship with his/her parents.

Describe your child's relationship with his/her siblings.

Did you utilize any specific program during his/her toddler years (Baby Einstein, Leap Frog, My Baby Can Read, etc.)?

What does your child do in his/her leisure time? Explain his/her hobbies and interests.

What is currently your child's favorite toy? In toddler years?

Does your child utilize any kind of digital media gaming device (iPad, Wii, Playstation, etc.)?

Does your child have any history of emotional problems?

Provide a brief school history for child including school name and age/grades completed.

List any psychiatrists, therapists, tutors, or learning disabilities specialists your child works with or has worked with in the past. Provide contact information if possible.

Please provide a medication history, if applicable.

Has your child displayed behavior problems at school? At home?

What is child's current level of motivation to learn?

What do you perceive to be your child's strengths, abilities, and talents in school?

What aspect of school does your child like most?

What do you perceive to be your child's outstanding difficulties in school?

What aspect of school does your child like least?

What would you like to accomplish from your relationship with Academics Plus

In order to fully understand your child's strengths and weaknesses, it is important that we know about his/her parents' strengths and weaknesses. Please tell us about each parent's occupation and strengths and weaknesses.

Learning Checkup Parent Questionnaire