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EARLY CHILDHOOD TEACHER/CAREGIVER QUESTIONNAIRE

(If child is enrolled in a daycare/nursery school/babysitter)

Student Name:*
Teacher/Caregiver Name:*
Date of Birth:*
Phone:
Email:
Date of Completion:
School:

Please check "Yes" if you have any concerns about the following areas of development.

Cognitive:

(play skills, attention to task, remembering and readiness activities)

Cognitive Strengths:
Cognitive Needs:
Social/Emotional:

(ability to engage others and interact in their environment, follow routines, directions, learn rules and expectations)

Social/Emotional Strengths:
Social/Emotional Needs:
Communication:

(understand and express wants, needs and ideas, articulation)

Communication Strengths:
Communication Needs:
Fine Motor:

(manipulating toys, pre-writing skills, small muscle development)

Gross Motor:

(sitting, standing, moving from place to place, large muscle development)

Motor Strengths:
Motor Needs:
Adaptive Skills:

(self-care skills-feeding, dressing/undressing, hygiene/toileting, sleeping)

Adaptive Skills Strengths:
Adaptive Skills Needs: