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Teacher Questionnaire – School Functioning & Concerns

Teacher-completed questionnaire to describe classroom functioning, concerns, strategies tried, and effectiveness.

"*" indicates required fields

This field is for validation purposes and should be left unchanged.

I. Teacher & Classroom Information

II. Student Information

III. General Areas of Concern

Please indicate any areas in which you have concerns about this student’s functioning at school (select all that apply).

IV. Domain-Specific Follow-Up Sections

A. Attention / Focus

Specific concerns (select all that apply):
Strategies or supports that have been tried (select all that apply):
Effectiveness of strategies tried:

B. Hyperactivity / Impulsivity

Specific concerns (select all that apply):
Strategies or supports that have been tried (select all that apply):
Effectiveness of strategies tried:

C. Executive Functioning

Specific concerns (select all that apply):
Strategies or supports that have been tried (select all that apply):
Effectiveness of strategies tried:

D. Academic Skills – Reading

Specific concerns (select all that apply):
Strategies or supports that have been tried (select all that apply):
Effectiveness of strategies tried:

E. Academic Skills – Writing

Specific concerns (select all that apply):
Strategies or supports that have been tried (select all that apply):
Effectiveness of strategies tried:

F. Academic Skills – Math

Specific concerns (select all that apply):
Strategies or supports that have been tried (select all that apply):
Effectiveness of strategies tried:

G. Language / Communication

Specific concerns (select all that apply):
Strategies or supports that have been tried (select all that apply):
Effectiveness of strategies tried:

H. Social Skills / Peer Interaction

Specific concerns (select all that apply):
Strategies or supports that have been tried (select all that apply):
Effectiveness of strategies tried:

I. Emotional Regulation

Specific concerns (select all that apply):
Strategies or supports that have been tried (select all that apply):
Effectiveness of strategies tried:

J. Anxiety / Worries

Specific concerns (select all that apply):
Strategies or supports that have been tried (select all that apply):
Effectiveness of strategies tried:

K. Behavior / Compliance

Specific concerns (select all that apply):
Strategies or supports that have been tried (select all that apply):
Effectiveness of strategies tried:

L. Memory / Learning Retention

Specific concerns (select all that apply):
Strategies or supports that have been tried (select all that apply):
Effectiveness of strategies tried:

V. Strengths & Overall Impressions

Compared to same-age peers, overall functioning is:
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