Joseph F. Kulas, Ph.D.

, ABPP
Board Certified
Clinical Neuropsychologist

270 Farmington Avenue Phone: (203) 805 - 8527

Suite #344 Fax: (203) 271-2320
Farmington, CT 06032 JosephKulas.Ph.D.@neuropsychology ct.org
http://www.neuropsychologyct.org

PRE-SCHOOL - KINDERGARTEN QUESTIONNAIRE

Student's name: _____________________________ BD: _______________________

Name of school: _______________________________________Phone: ____________

Address of school: ______________________________________________________

Present grade: Preschool ____number of days per week

Kindergarten ____ half day program ___ full day
program

General class size: _______________ Student/teacher ratio: ________________

Is this child frequently absent/tardy? Yes No

Is this child receiving special services? Yes 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 Multiply-handicapped
Emotional Disturbance Non-categorical
LD Other Health Impaired (ADHD)
Speech Neurologically Impaired
Language Autism
Hearing Impaired 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

III. PRESCHOOL/READINESS
Overall readiness skills are at the ________ age level

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 PRE-SCHOOL - KINDERGARTEN QUESTIONNAIRE

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:

_______________________________________________________________________

_______________________________________________________________________

V. HEARING:

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 PRE-SCHOOL - KINDERGARTEN QUESTIONNAIRE

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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