Yes No 1. Is your child’s room messy?

Yes No 2. Does your child always know what needs to be done for homework?

Yes No 3. Does your child lose homework papers or forget to give them to the teacher?

Yes No 4. Does your child have trouble staying focused to complete the homework without parental assistance?

Yes No 5. Does your child need reminders to complete tasks?

Yes No 6. Is your child’s locker a frightening, disorganized sight?

Yes No 7. Is your child’s backpack overflowing with loose papers and other “stuff?”

Yes No 8. Does your child procrastinate on long–term assignments/projects?

Yes No 9. Does your child have trouble scheduling on a calendar when he will be doing things?

Yes No 10. Does your child have a problem completing tasks?

Yes No 11. Does your child get overwhelmed easily?

Yes No 12. Does your child have trouble estimating how long a task will take?

Yes No 13. Does homework seem to take “forever?”

Yes No 14. Is your child shocked when she is told there are missing assignments?

Yes No 15. Does your child understand how devastating a zero is to his overall grade?

Yes No 16. Does your child know how to study using his learning style?

Yes No 17. Does your child know what to do to help her concentrate better in school?

Yes No 18. Does your child know the structures necessary to make good grades?

Yes No 19. Does your child know the value of homework?

Yes No 20. Does your child have trouble processing auditory information?

Yes No 21. Does your child study well enough for a test to remember the information long–term?

Yes No 22. Does your child rely on a parent to help him study?

Yes No 23. Does your child get lost in the process of writing an essay or research paper?

Yes No 24. Does your child have trouble proofreading her papers?

Yes No 25. Is your child a “picky” eater, or does he crave certain foods on a daily basis?

Yes No 26. Does your child have trouble going to sleep?

Yes No 27. Does your child have trouble staying asleep?

Yes No 28. Does your child have trouble getting up in the morning?

Yes No 29. Does your child know when her ADHD medicine “kicks in?”

Yes No 30. Does she know when the medicine is gone?

Yes No 31. Does your child suffer from loss of appetite?

Yes No 32. Does your child suffer from depression or aggressive behavior?

Yes No 33. Does your child have sleep problems?

Yes No 34. Does your child appear lazy or unmotivated?

Yes No 35. Does your child suffer from low self–esteem?

Yes No 36. Does your child have trouble making and/or keeping friends?

Yes No 37. Do you as a parent catch yourself rescuing your child too often?

Yes No 38. Does your child have trouble admitting that the situation is his fault?

Yes No 39. Does your child act immature for her age?

Yes No 40. Does your child have trouble “getting his engine going” in the morning?

Yes No 41. Does your child struggle with reading skills?

Yes No 42. Does your child struggle with spelling?

Yes No 43. Does your child struggle with math?

Yes No 44. Does your child have trouble keeping math columns aligned?

Yes No 45. When your child is writing, does she get really close to the paper?

Yes No 46. Does your child have an awkward pencil grasp?

Yes No 47. Does your child claim that his fingers hurt when he is writing?

Yes No 48. Is your child experiencing behavior problems at school and/or at home?

Yes No 49. Is your child afraid to ask questions in school if she is confused?

Yes No 50. Does your child have trouble setting and meeting goals?

Rank your child's top two problem areas. Type the numbers in the space provided.

1.

2.