Student Name:
Family Member Name(s):
Family Questionnaire for Individualized Education Program
Please answer questions regarding your child’s educational experiences. The information you provide
will be documented in the section of the Individualized Education Program reserved for parent concerns.
1. What are your goals for your child in the next year?
2. What are your child’s strengths?
3. What are your child’s greatest needs?
Describe how your child feels about school.
5. Describe academic concerns that you have for your child
(e.g., reading, math, spelling, writing, science).
Student Name:
Family Member Name(s):
6. Describe behavioral concerns that you have for your child, if any
(e.g., time management, on-task behavior, working memory, motivation,
organization, task completion).
7. Describe academic skills that your child practices at home
(e.g., drawing, reading, arts and crafts, math facts, story writing, computer
8. Does your child take medication? If so, please provide the name, dosage,
and frequency of the medication.
9. Please provide any additional concerns that were not addressed in the