FAMILY SURVEY

Please fill out and return this survey with your student.

STUDENT NAME:

PARENT/GUARDIAN NAME:

RELATIONSHIP TO STUDENT:
( )
EMAIL: PHONE:

ADDRESS:

LANGUAGE SPOKEN AT HOME:

BEST METHOD & TIME TO CONTACT YOU ABOUT YOUR STUDENT:

Email Text Call Time of Day: 3pm – 6pm

6pm – 9pm
Other:

1. What are some of your student’s strengths? (Personality, athletics, art, musical, social, academic)

2. Where do you think your student needs the most support? (Writing paragraphs, reading,
making friends etc.)

3. What motivates your student?

4. What are your goals for your student?

5. Is there anything else you’d like to tell me? (Allergies? Habits? Questions?)