Student Assistance Program - Parent/Guardian Questionnaire

Please complete the Parent Consent form first!

Student Name: Student Name: First Last
Child's School Building
Date: Date: / MM / DD YYYY
Parent/Guardian Name: Parent/Guardian Name: First Last
Relationship to Student:
Strengths:
Please check all that you believe apply to your son or daughter.

Strengths:
Please check all that you believe apply to your son or daughter. Able to work independently Joins in extra activities at school or in community Works well in a group Wants to and likes to learn Displays good logic/reasoning and decision making Is a good leader Can accept criticism Considerate of others Good communication skills Cooperative Possesses good interpersonal skills Displays positive values (responsibility, honesty, equality, caring) Follows rules Uses time wisely Helps others Is connected to and likes school and staff Strives to achieve their best Other Other
Positive Traits at Home:
Please check all that describes your son or daughter's behavior at home. (Check all that apply)

Positive Traits at Home:
Please check all that describes your son or daughter's behavior at home. (Check all that apply) Generally complies with family rules, curfews, etc. Does household chores Participates in family activities, meals, etc. Cares about appearance, health, etc. Takes appropriate pride in self and their possessions, keeps room reasonably neat Behavior is appropriate with peers and sublings Generally respectful toward parent(s)/caregiver(s) and others Other Other
Personality:
Have you observed any of the following with regard to your son or daughter's personality? (Check all that apply)

Personality:
Have you observed any of the following with regard to your son or daughter's personality? (Check all that apply) Noticeable mood swings Frequent, extreme highs or lows Crying seemingly without explanation Appearing very irritable or hostile without reason Extremely negative or apatheic attitude Spending a lot more time alone, in his/her room Exhibiting general loss of energy, motivation, interest or enthusiasm; is increasingly uninterested Other Other
Friends/Relationships:
Have you observed any of the following with regard to your son or daughter's friends/relationships? (Check all that apply)

Friends/Relationships:
Have you observed any of the following with regard to your son or daughter's friends/relationships? (Check all that apply) Stopped spending time with old friends Hanging out with friends you don't know Doesn't want you to meet his or her friends Friends immediately go to the child's room avoiding contact with family members Son or daughter receiving many short phone calls Son or daughter not where they tell you they are Spends less time in family activities Is verbally or physically abusive of family members Blaming others; refusing to take responsibility for self Refuses to follow family rules Other Other
Physical Traits:
Have you observed any of the following with regard to your son or daughter's physical appearance/traits? (Check all that apply)

Physical Traits:
Have you observed any of the following with regard to your son or daughter's physical appearance/traits? (Check all that apply) Unsteady on feet Noticeable change in weight Complaining of nausea/stomach ache Glassy/bloodshot eyes Unexplained physical injuries Poor motor skills Frequent cold-like symptoms Smelling of alcohol/marijuana Slurred speech Loss of hair Self-abuse or self-mutilation Doesn't keep self clean/poor hygiene Preoccupied with personal health issues Fatigue/constantly tired Disoriented Change in sleep habits Headaches Food issues (example: refusal to eat, etc.) Please explain:
Crisis Indicators:
Please check all that you have observed with regard to your son or daughter.

Crisis Indicators:
Please check all that you have observed with regard to your son or daughter. Has expressed desire to die Given away personal possessions Has expressed desire to join someone who has died Has made suicidal threats/gestures Has experienced a recent death of family member or close friend Other stressors (please explain): Other stressors (please explain):
School:
Have you observed any of the following with regard to your son or daughter's school experience? (Check all that apply)

School:
Have you observed any of the following with regard to your son or daughter's school experience? (Check all that apply) Experiencing more problems in school than usual Recent or rapid drop in grades Stopped participating (or showing less interest) in extracurricular activities such as sports, clubs, etc. Caught forging notes to his/her teacher or excuses for absences from school Having problems getting your child to go to school Wants to drop out of school Other Other
Legal/Financial:
Is your son or daughter experiencing any of the following legal or financial problems? (Check all that apply)

Legal/Financial:
Is your son or daughter experiencing any of the following legal or financial problems? (Check all that apply) Arrests for drinking/drug use/DUI/possession/other illegal acts Curfew violations Recently sold personal possessions Quit a job or lost a job due to unsatisfactory job performance Seems to have more money than job or allowance would provide Been caught with drugs and/or alcohol Been caught with products associated with drug use/paraphernalia Been caught taking things from home or neighbor's homes Family members missing money or items from the home (cameras, stereos, watches, TV's, etc.) Other Other
What are your concerns for your child that may be a barrier to his or her learning?
What does your child tell you about his or her school experiences?
Would you like to speak directly with a member of the SAP Team?

Would you like to speak directly with a member of the SAP Team? Yes No