Getting Started

Questionnaire

Please read each of the following statements and rate your student by selecting a number from 0 to 4 for each statement. Be sure to complete all the items. When you have completed the Questionnaire we ask that you e-mail it back to us by clicking on the send button at the bottom. We will email you with the results. Please answer all 64 of the questions to the best of your ability. 

We Respect Your Privacy.  We do not share your information with anyone.
 

COMPARED TO OTHER STUDENTS THE SAME AGE...

Name:     Required E-Mail:     Required Address:     Required City:     Required State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming     Required Zip Code:     Required Day Phone: Evening Phone: Message: 0 1 2 3 4 Q1 - Is careless 0 1 2 3 4 Q2 - Fidgets or squirms 0 1 2 3 4 Q3 - Swears or uses obscene language 0 1 2 3 4 Q4 - Often asks to have things repeated 0 1 2 3 4 Q5 - Has difficulty maintaining attention 0 1 2 3 4 Q6 - Overreacts