685 Leese Road, Lynchburo, VA 24502 CENTRA phone: 44 2006750 ‘Autism & Developmental Services fax: 434.200.1662 ‘wurw.centraautism.com SCHOOL QUESTIONNAIRE ‘Student's Name: Date: This form was completed by: Title: Name of School: Grade in School: Has he/she ever repeated a grade? __If' so, which? Type of school program: General Special Education If special education, please describe: Academic Subject’ | Far Below | Below Average ‘Above Far Above Developmental Area _| Average | Average Average | Average Student's Level of Effort What concerms you most about your student? Describe your student's strengths and what you like best about your student: Please return this document to the address or fax number provided at the top of the page.