Parent/Caregiver Interview

For Students Who Are English Learners

Childs Name: DOB: Grade:

Person Interviewed:

Relationship:

Home Phone:

Address:

Cell Phone:

Work Phone:

School:

Interviewer(s):

Date:

**Introduction as to why you are calling** For example, Hello, this is ___________ (provide name, school, your position). As you know, your childs teacher has shared some concerns with you regarding ___________. I am calling you today in order to gather some additional information about your child. It is important for us to understand what your concerns may be. We will use this information to determine how to best meet your childs needs. This may help us to generate an intervention plan or may lead to a referral to the schools special education team for a more in-depth evaluation. What languages are spoken in your home?

Would you like an interpreter for school meetings? **Complete the Districts Interpreter Form**

General Questions
Has your child ever been evaluated outside of school or while attending another school district? Please describe. **If yes, request a copy or a Release of Information.**

What are some of your childs strengths? What is he or she good at?

In a few words, how would you describe your child?

What is your view on how the interventions have impacted your childs learning?

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Family History
How long has the family been in the country? Where have you lived in the United States?

Did you ever live in a refugee camp? If so, how long and where?

Who does your child live with? What was the highest grade or level of education completed by each person the child lives with? If parents do not live together, does your child spend time at both homes? Please describe:

Does anyone in the childs immediate or extended family have a history of significant medical or mental health concerns, such as anxiety, depression, bipolar disorder, ADHD, etc.?

Are you concerned about any emotional trauma or stress that your child may have experienced?

Are there significant changes in the life of your child that may be affecting school performance?

Are there cultural or racial factors that are affecting your child at school?

Prenatal and Birth History:

Were there any complications during pregnancy or delivery (please describe)?

Weeks Gestation:________

Birth Weight: ________

Prior to your knowledge of your pregnancy or anytime throughout the pregnancy, is there any possibility of exposure to alcohol, tobacco, or drugs (including prescription medications)?

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Were there any concerns during the first month after birth (ex. Oxygen therapy, feeding difficulties, respiratory distress, infection, etc.)?

As an infant, did your child like to be held? If no, please describe.

Was your child easily soothed when upset? Please describe.

Developmental History
Has there ever been a concern with your childs early development/milestones (please describe)? Were developmental milestones met within a typical age range (e.g., crawling, walking, talking, toileting)? Please share some examples.

Medical/Health History:
Has your child ever had any serious illnesses or conditions?

(For secondary students): Has your child ever used alcohol, tobacco or drugs? If so, how often? How did you become aware of this?

Describe your childs eating and sleep patterns. Has your child ever had eating or sleeping difficulties?

Does your child have a medical or mental health diagnosis? Please describe.

**If there is a medical or mental health diagnosis, complete the following questions. Otherwise continue to Academic section. (S) Are there special considerations that the school needs to be aware of? o Medical: o Health: o Safety:

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(S) What are your priorities for the staff and your child to work on at school?

(S) How much does your child know about his/her medical diagnosis?

(S) Do you want staff to provide an inservice to your childs classmates? o Would you like to participate in the inservice? o Do you want your child to be present at the inservice?

(S) How would you like to communicate with school staff about your child and the medical condition? Do you prefer one contact person?

(S) Have you talked to the school nurse about medications or health concerns?

Does your child take any medication? What medication are they taking? Dosage?

Have you noticed any changes in your childs behavior since he began taking this medication?

Have they taken any medications in the past (other than for illness)?

Does your child receive any outside therapies? Please describe.

Share examples of how your child organizes himself/herself at home to things like: chores, getting ready for school in the morning, and room cleaning. Do they follow a routine? Can they see a task through to completion or start another task before finishing the first? Is this significantly different from other members of the family?

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Academic
How old was your child when (s)he started school? Please list all schools your child has attended: What was the language of instruction? How did your child do in their previous schools?

Can your child read in any language? Which language(s)? Please describe.

Do you currently have concerns regarding your childs academic progress (please describe)? Reading Does your child have trouble reading words? Sentences? Books?

Does your child understand what they read? Does your child talk about what they read?

How does your child read new words? Doe they ask for help right away? Doe they try to sound out the words?

In your opinion, does it take your child a long time to read?

How much does your child read independently at home? What does your child read at home?

Math

Can your child answer addition problems? Subtraction? Multiplication? Division?

Can your child figure things out using numbers? (May need to give examples).

Writing What does your child use writing for? Can you understand what your child writes? If not, is this due to penmanship, spacing, spelling, or something else?

Does your child write from left to right?

Can your child write letters to form words?

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Do you notice any other problems in reading? Writing? Math?

Basic Psychological Processing Does your child understand stories read or told to her?

How does your child recall information? What strategies do you know he or she uses? What happens when your child forgets things?

Is your child able to use previously learned information in new situations?

Does your child remember routines?

How would you describe your childs ability to organize (objects, thoughts, use of time)?

Are there things that you or another family member are doing at home to help your child learn?

Compared to siblings, how would you describe your childs academic performance?

Has your child ever been retained/repeated a grade? Has this ever been recommended by school staff? Please describe:

How much time does your child typically spend on homework each evening? How much assistance does your child need? What strategies have worked at home?

Has your child ever received any special services either through school or outside of school (e.g., special education, speech therapy, occupational therapy, counseling, etc.)?

Has your child ever shown resistance to attending school?

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Communication
What language did your child speak when (s)he first began to talk?

When did your child first begin to learn English?

How old was your child when they said their first words in your native language? In English?

Do you feel your child started talking at about the same time as other children? Earlier? Later?

Describe early concerns, if any, regarding your childs speech/language development (e.g., delays, making speech sounds, echolalia, jargon speech, stuttering, pronoun reversals).

Which language do you typically use when speaking to your child?

Which language does your child typically use for the following activities (circle)? Speaking with parents English Native Language Speaking with siblings English Native Language Speaking with peers English Native Language Listening to the radio English Native Language Watching TV English Native Language Playing board games English Native Language Playing cards English Native Language Using the computer English Native Language Reading books/magazines English Native Language Listening to music English Native Language Playing sports English Native Language Dance or other lessons English Native Language At church, temple, mosque, etc. English Native Language Going shopping English Native Language Other community activities English Native Language Which is your childs best language?

Both Both Both Both Both Both Both Both Both Both Both Both Both Both Both

Does (s)he answer your questions in English or his/her native language?

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Does your child switch between your native language and English in the same sentence? If so, does it make sense when (s)he does this?

Does your child use correct grammar in your native language?

Does your child know as many words as other children in your native language? Does (s)he often not know the word for something or use the wrong word in your native language?

Does your child usually say only one or two words at a time, or does (s)he usually use longer sentences? In native language? In English?

Describe current concerns, if any, regarding your childs communication (e.g., rarely initiates conversation, has difficulty carrying on a back and forth conversation, changing topics midconversation, has difficulty understanding humor, likes to only talk about topics of interest to him or her, difficulty understanding nonverbal cues such as facial expression or tone of voice).

Do you have any concerns with your childs ability to express their ideas clearly and completely in either language? Please describe.

Do you have any concerns with your childs ability to understand what is said to them in either language? Please describe.

Do you have any concerns with your childs ability to follow directions (one-step directions, twostep, more than two steps) in either language? Please describe.

Do you have any concerns with the way your child makes speech sounds in either language? Please describe.

Does your child repeat words or sounds, or struggle to get words out when he/she is talking (e.g., I...I...I..., and...and...and...)?

Does your childs voice often sound different than other children his age (e.g., hoarse, raspy, breathy)?

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Functional/Self-Help Skills
Describe your child's level of independence with the following types of tasks. o o o o o o o Personal self-care Preparing food or snacks Chores Following directions or initiating tasks on own Telling time/sense of time for various activities Calendar skills General safety rules

Motor Skills
Do you have any concerns with your childs fine motor skills (e.g., writing neatly, cutting, coloring)? Please describe.

Do you have any concerns with your childs large motor skills (e.g., running, jumping, catching, throwing, etc.)? Please describe.

Behavior
Have there been concerns regarding your child's behavior in the past? Please describe.

When did you first notice these behaviors?

What are the behaviors, if any, that you are concerned about at this time?

**If there are no concerns with behavior, skip to the Social Skills section.**

When did you first notice these behaviors?

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Do you know of any interventions or strategies that have helped your child manage these behaviors?

How often do these behaviors occur?

Where are these behaviors most and least likely to occur?

With whom are these behaviors most and least likely to occur?

Do you notice any patterns with when the behaviors occur, such as certain times of day, days of the week, times of the year?

How long does this behavior last?

Would you describe the intensity/level of danger of this behavior as low, moderate, or high?

How is your child best calmed?

What seems to happen just before the behavior occurs (what sets them off)?

What one thing could you do to most likely make the problem behavior(s) occur?

What things should a teacher avoid doing that might disrupt an activity?

How would the behavior be affected if you: asked your child to perform a difficult task, interrupted a fun activity, unexpectedly changed a routine/schedule, denied a request, or didnt pay attention to your child for several minutes?

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What seems to happen just after the behavior occurs (what do you and others around your child do, what does your child do, does your child seem to be gaining or avoiding anything as a result of the behavior)?

Are there any disciplinary techniques that have helped improve the situation?

Are there any disciplinary techniques that have made the problem worse?

What have you found to be the most satisfactory way of helping your child?

What are some things that may be potentially reinforcing for your child (for example, specific foods, toys/objects, activities at home/community, or special people)?

Why do you think your child engages in this behavior (e.g., avoid or escape tasks/situations, gain control, to be accepted by others, get or avoid attention, poor impulse control, sensory, or other physical/biological reasons)?

Social Skills
Does your child have friends in your neighborhood? Same age, older or younger? If no, do they ever express that they would like to have friends? Does this cause frustration?

What does your child enjoy doing with his/her friends?

What concerns, if any, do you have about your childs social skills and social interactions with others?

**If no concerns with social skills, skip to the Sensory section. ** Describe how your child interacts with other children and adults.

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Does your child demonstrate emotional reactions sometimes unrelated to the events/objects around them? Please describe.

Does your child demonstrate any of the following: Social isolation/withdrawal? Disinterest in other people/aloofness? Preference for interaction with toys or other objects rather than people? Inappropriate or peculiar social approaches? Difficulty making/maintaining friendships? Needs to have his/her own way when interacting with others? Insensitivity to other persons feelings? Insistence on routines or following rules?

Sensory/Activities and Interests

Has your child's vision been formally evaluated? When: Results: Do/did you have concerns about your childs visual response (e.g., staring, avoiding eye contact, holding objects close to eyes, needing reminders to look at objects or people, interest in mirrors/lights, etc.)?

Has your child's hearing been formally evaluated? When:

Results:

Did your child have frequent ear infections? PE Tubes?

Do/did you have concerns about your childs hearing (e.g., lack of response or delayed response to sounds, startles or covers ears in reaction to everyday sounds, distracted by noise)?

Do/did you have concerns about your childs response to touch (e.g., avoids/becomes irritated by certain clothing; shows sensitivity to certain textures/temperatures; persistently mouths objects; over- or under-reaction to mild pain; resists bathing, brushing teeth, haircuts, etc.; exhibits clingy behaviors; shows discomfort when approached/touched; insists on large personal space; has picky eating habits)?

Do/did you have any concerns about your childs body movements through space (e.g., falls or trips often, loses balance easily, has problems hopping or skipping, likes to rock/swing/spin, bumps into objects, uses one hand for two-handed activities)?

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Does/did your child engage in repetitive behaviors (e.g., flap hands/stamp/clap/jump to an unusual degree, toe-walk, climb in inappropriate places, bang head)?

Do you have any concerns with your childs variety of play activities, interests, conversation topics? If so, please describe.

Does your child adapt well to changes in routine/schedule? If no, please describe.

Does/did your child have any seemingly unreasonable fears and anxious reactions to the fears? Please describe.

Transition (High School Students Only)

What would you like your son/daughter to be doing after high school?

Do you have ideas about jobs you or your son/daughter are interested in?

If you would like him/her to be going to school after high school, where are you considering?

How independent will he/she be in supporting himself/herself financially after high school?

Where would you like him/her to live after high school?

What community or leisure activities do you hope he/she participates in after high school?

What transportation system(s) do you see him/her using in the community?

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Do you think your child will need support in taking care of himself/herself physically and emotionally? If yes, please explain.

What kind of support will he/she need in making decisions and setting goals that need to be made about his/her life?

Other Follow-Up Questions

Is there anything else that you would like the school to know about your child?

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