Community HELP Parent Questionnaire

Child's Date of Birth(Required)

Relationship to Child

Your primary phone number(Required)

Please list any other phone numbers (if applicable) that we can use to contact you.

What learning problems has your child been diagnosed with?(Required)

Is there a family history of learning problems or attentional disorders?(Required)

What has been done/is being done to help your child in school?

Please rank your child’s ability in the following areas.