Pre-Assessment Survey

maria@rewireadhd.com

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PRE-ASSESSMENT SURVEY

Please answer these 28 questions as honestly as possible. Your responses will help me support your son/daughter in reaching their goals.

by Maria Sevilla 2022 based on the work of Dawson, Guares and EF Specialists

Name of Parent (if Client/Child is 18 and Under)

First

Last

Name of Client *

First

Last

Email *

1. They can listen to someone speaking without interrupting. *

1 - Never
2
3
4
5 - Most of the time

2. When they receive an upsetting social media post or text message they take their time to think about their reply before answering back. *

1 - Never
2
3
4
5 - Most of the time

3. When taking a test, they remember the information they studied. *

1 - Never
2
3
4
5 - Most of the time

4. They remember to complete and turn in homework assignments. *

1 - Never
2
3
4
5 - Most of the time

5. They remember all the tasks and chores they have to do daily and complete them without looking at a list or forgetting anything. *

1 - Never
2
3
4
5 - Most of the time

6. They can communicate respectfully with others, even if they don't agree with them, and be tolerant to their opinions and points of view. *

1 - Never
2
3
4
5 - Most of the time

7. They use strategies to manage their emotions when they feel angry, frustrated, annoyed or overwhelmed. *

1 - Never
2
3
4
5 - Most of the time

8. They are able to pay attention in class without getting distracted. *

1 - Never
2
3
4
5 - Most of the time

9. They are able to complete their homework without getting distracted. *

1 - Never
2
3
4
5 - Most of the time

10. They can start their homework without being reminded. *

1 - Never
2
3
4
5 - Most of the time

11. They can start their chores without being reminded. *

1 - Never
2
3
4
5 - Most of the time

12. They have (and use) a calendar system to keep track of their school assignments and other responsibilities. *

1 - Never
2
3
4
5 - Most of the time

13. They are able to chunk big projects into smaller parts. *

1 - Never
2
3
4
5 - Most of the time

14. They have a designated work space for studying and homework completion that is organized and distraction free. *

1 - Never
2
3
4
5 - Most of the time

15. They keep their room clean. *

1 - Never
2
3
4
5 - Most of the time

16. They keep their back pack and school materials organized. *

1 - Never
2
3
4
5 - Most of the time

17. They can estimate how long and assignment, project or chore will take them to complete. *

1 - Never
2
3
4
5 - Most of the time

18. They use their time effectively. *

1 - Never
2
3
4
5 - Most of the time

19. They feel motivated to reach their goals. *

1 - Never
2
3
4
5 - Most of the time

20. They can set a realistic goal for themselves. *

1 - Never
2
3
4
5 - Most of the time

21. They are capable of dealing with last minute change in plans. *

1 - Never
2
3
4
5 - Most of the time

22. They are open to learning new ways of how to do things. *

1 - Never
2
3
4
5 - Most of the time

23. They reach goals they set for themselves. *

1 - Never
2
3
4
5 - Most of the time

24. If a strategy they use on a given task doesn't work at first, they are capable of making the necessary changes to complete the task more efficiently in their next attempt. *

1 - Never
2
3
4
5 - Most of the time

25. They know how and what to study for exams, quizzes and tests. *

1 - Never
2
3
4
5 - Most of the time

26. They use multiple strategies to study for exams, quizzes and tests. *

1 - Never
2
3
4
5 - Most of the time

27. They are comfortable approaching their teachers (virtually and in person) to ask for help when necessary. *

1 - Never
2
3
4
5 - Most of the time

28. They are comfortable asking their teachers to implement their accommodations. *

1 - Never
2
3
4
5 - Most of the time

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Pre-Assessment Survey

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First Name

Last Name

Email address:

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