Child's Name
*
First Name
Last Name
Child's Current Age
*
Child's Current School & Grade
*
Does your child have a diagnosis of any of the following:
*
How behind is your child with assignments?
*
Please provide a brief description:
How motivated is your child to catch up on missing work or complete assignments before the end of the year?
*
1 Never motivated
2 Sometimes motivated
3 Often motivated
4 Always motivated
How important is academic performance to your child?
*
1 Not at all important
2 Somewhat important
3 Often important
4 Extremely Important
How independent is your child with completing homework (when aware of assignments)?
*
1 Not at all independent
2 Somewhat independent
3 Often independent
4 Extremely independent
How much support do you provide your child with homework?
*
1 No support
2 Some support
3 Moderate support
4 Significant amount of support
Has your child tried strategies or interventions for executive functioning and work completion before?
*
If so, please describe the strategy and level of success:
How anxious is your child about school?
*
1 Not at all anxious
2 Sometimes anxious
3 Often anxious
4 Always anxious
How comfortable would your child be participating in a virtual Zoom group with a small group of other students?
*
1 Not at all comfortable
2 Somewhat comfortable
3 Mostly comfortable
4 Extremely comfortable
How comfortable would your child be discussing executive functioning difficulties with other group members?
*
1 Not at all comfortable
2 Somewhat comfortable
3 Mostly comfortable
4 Extremely comfortable
How open is your child to receiving support for completing assignments?
*
1 Not at all open
2 Somewhat open
3 Mostly open
4 Extremely open
How significant are your child’s executive functioning struggles?
*
1 Very mild
2 Moderate
3 Significant
4 Severe
Would you say that your child struggles with Impulsivity?
*
(e.g. Rushing through, giving up, poor quality work)
Would you say that your child struggles with Working Memory?
*
(e.g. Forgetting to take down, complete, or hand in work; doesn’t check
planner, loses materials, difficulty remembering directions)
Would you say that your child struggles with Emotional Control
*
(e.g. Easily frustrated by challenging work, perfectionism, hard to motivate)
Would you say that your child struggles with Task Initiation
*
(e.g. Procrastinating, not sure how to get started, doing fun things instead, difficulty getting back to work after breaks)
Would you say that your child struggles with Sustained Attention?
*
(e.g. Easily distracted, frequent breaks, loss of focus)
Would you say that your child struggles with Planning and Prioritization?
*
(e.g. Trouble making a schedule or breaking down long-term assignments, disorganized, poor time management)
Would you say that your child struggles with Flexibility?
*
(e.g. Getting stuck on one solution or one way of working, trouble coming up with ideas or ways of solving problems)
Would you say that your child struggles with Organization?
*
(e.g. Can’t find homework materials, losing assignments or electronic information, difficulty using planner or keeping track of work)
Would you say that your child struggles with Time Management
*
(e.g. Can’t estimate how long something will take, chronically late, no sense of urgency)
Would you say that your child struggles with Goal Directed Persistence?
*
(e.g. Difficulty planning steps needs to reach goals, “good
enough” mentality, giving up easily)
Would you say that your child struggles with Metacognition?
*
(e.g. Poor memory/retention, limited understanding of own strengths and weaknesses)
Your name
*
First Name
Last Name
Best email to contact you
*
Best phone number to contact you
*
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