Joseph F. Kulas, Ph.D., ABPP
Board Certified
Clinical Neuropsychologist
270 Farmington Avenue
Suite #344
Farmington, CT 06032
http://www.neuropsychologyct.org
Phone: (203) 805 - 8527
Fax: (203) 271-2320
JosephKulas.Ph.D.@neuropsychology ct.org
PRE-SCHOOL - KINDERGARTEN QUESTIONNAIRE
Student's name: _____________________________ BD: _______________________
Name of school: _______________________________________Phone: ____________
Address of school: ______________________________________________________
Present grade:
Preschool
Kindergarten
____number of days per week
____ half day program ___ full day program
General class size: _______________ Student/teacher ratio: ________________
Is this child frequently absent/tardy?
Is this child receiving special services?
Yes
Yes
No
No (If “no”, go to II)
I. SPECIAL SERVICES
A. Educational setting:
residential
Name of facility: ___________________________________________
Address: ___________________________________________________
self-contained with no mainstreaming
resource room
special education within the mainstream class
tutorial intervention
title intervention
speech and language
OT/PT
other (please specify)
____________________________________________________________
PRE-SCHOOL - KINDERGARTEN QUESTIONNAIRE
B. Educational Exceptionality:
ID
Emotional Disturbance
LD
Speech
Language
Hearing Impaired
Multiply-handicapped
Non-categorical
Other Health Impaired (ADHD)
Neurologically Impaired
Autism
Visually Impaired
C. Intervention (please specify):
1. Area of intervention: __________________________________
Frequency: _________________________ Class size: ___________________
2. Area of intervention:
Frequency: _________________________ Class size: ___________________
3. Area of intervention:
Frequency: _________________________ Class size: ___________________
4. Are special modifications necessary in the regular classroom? If so,
please give a brief description.
______________________________________________________________________
II. FORMAL EVALUATIONS (testing)
Please provides dates of last developmental/readiness assessments:
Date of
Type of evaluation
Evaluation
Educational Readiness
Psychological (cognitive and personality) evaluation
Speech and language assessment
Occupational therapy evaluation
Physical therapy evaluation
Other:
Please enclose copies of all above mentioned testing completed on this child
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PRE-SCHOOL - KINDERGARTEN QUESTIONNAIRE
III. PRESCHOOL/READINESS
Overall readiness skills are at the ________ age level
COGNITIVE/PRE-ACADEMIC SKILLS
The following skills may or may not have been introduced within your
school program. Please check those areas in which this child
demonstrates facility in accordance with his/her peer group. Please
check all that apply.
A. General development/readiness skills:
1. Can this child give verbal responses to personal data questions (i.e.
name, age, address, etc.)?
Yes
No
Comments:________________________________________________________
2. Color recognition:
Matches visually (list colors):
_________________________________
Recognizes by pointing (list colors):
_________________________________
Identifies verbally (list colors):
______________________________________
3. Shape recognition:
Matches visually (list shapes):
______________________________________
Recognizes by pointing (list shapes):
______________________________________
Identifies verbally (list shapes):
______________________________________
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PRE-SCHOOL - KINDERGARTEN QUESTIONNAIRE
B. Reading readiness skills:
1. General orientation for reading:
displays left to right orientation
turns pages correctly in book
displays interest in books and stories
2. Alphabet knowledge:
rote recitation
visual recognition
visual matching
verbal identification
3. Sight word recognition:
recognizes first name
recognizes last name
recognizes other sight words
4. Listening/auditory skills:
attentive to stories
answers basic comprehension questions
demonstrates knowledge of consonant sounds
recognizes similarities and differences within words (i.e., rhyming,
word families, etc.)
Comments:
___________________________________________________________________________
___________________________________________________________________________
C. Mathematics readiness skills
1. Counting:
rote recitation (list): __________________________________
one-to-one correspondence
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PRE-SCHOOL - KINDERGARTEN QUESTIONNAIRE
2. Numerals:
visual recognition (list): _______________________________
verbal identification (list): _____________________________
3. Concepts:
directional/positional skills
temporal (time) awareness
size awareness (i.e., big/little)
categorizing according to size, shape, etc.
IV. SPEECH AND LANGUAGE HISTORY
1. Is English this child's primary language? _______________________
2. What language does this child use in the home?_________________
at school? ________________________
3. Do you feel this child has any other problems that affect his/her speech
or language?
_________________________________________________________________________
4. Describe any physical handicaps this child has that may interfere with
speaking.
_________________________________________________________________________
5. Is this child easily understood by family members? ___________________
non-family members? ________________
6. Have there been any recent changes (increase or decrease) in the
way this child communicates, e.g., sounds, words, understanding?
Yes
No If so, please describe:
_______________________________________________________________________
_______________________________________________________________________
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PRE-SCHOOL - KINDERGARTEN QUESTIONNAIRE
V. HEARING:
1. Are there concerns about this child's hearing?
Yes
No
2. Does this child respond to noises in his/her environment (i.e., telephone,
animal, cars, etc.)?
Yes
No
3. Does this child look at the speaker's face?
Yes
No
VI. SOCIAL/EMOTIONAL/BEHAVIORAL FUNCTIONING
1. Do you have any concerns regarding inattention, distractibility, and/or
level of activity?
________________________________________________________________________
________________________________________________________________________
2. Do you have any concerns regarding behavior (tantruming, withdrawn,
oppositional or aggressive behavior)?
________________________________________________________________________
________________________________________________________________________
3. Do you have any concerns regarding atypical or unusual behaviors
(perseveration, inconsistent eye contact, stereotypic movement)?
________________________________________________________________________
________________________________________________________________________
4. How does this child relate to his/her peer group? Please comment.
___________________________________________________________________________
___________________________________________________________________________
5. What behavioral interventions have been tried with the student? What
attempts have been made to involve the family?
___________________________________________________________________________
___________________________________________________________________________
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PRE-SCHOOL - KINDERGARTEN QUESTIONNAIRE
6. What has been the outcome of these interventions to date?
___________________________________________________________________________
___________________________________________________________________________
7. Are there any other concerns you wish to mention?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Completed by:
_________________________
Name
_________________________
Telephone
_________________________
Position/Title
_________________________
Date
_________________________
Name
_________________________
Telephone
_________________________
Position/Title
_________________________
Date
_________________________
Name
_________________________
Telephone
_________________________
Position/Title
_________________________
Date
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