Name:

Grade:

Gender:FM

Mother tongue:FrenchEnglishOther
If other, specify:

Language(s) spoken at home:FrenchEnglishOther
If other, specify:

My child has academic difficulties:^*YesNo

If yes, which one(s)?:

My child has an Individual Education Plan (IEP) at school:^*YesNo

My child has a learning disability:^*YesNo

If yes, which one(s)?:

My child has been held back a year at school before:^*YesNo

If yes, when and why?:

Organization skills and work methods:time managementmemorizationstudy methodsunderstanding instructionsnote takingtime management during evaluationsorganization (planner, binders, and locker)
If other, specify:

Basic French and Mathematics difficulties that can have an impact on other subjects:reading comprehensionoral comprehensionreading fluencyspellingwriting a texthandwriting/calligraphyusing reference materialplanning and structuring a textproblem solvinggeometrymathematical operations in general
If other, specify:

Attitude and behaviour:lack of effortlack of motivationability to pay attention in classrespecting instructionsnot studying enoughgiving up too easilybehaviour in class
If other, specify:

Anxiety and attention:anxiety during examsanxiety during oral presentationstrouble concentrating and paying attentiontrouble with teamwork
If other, specify:

Mrs.Mr.

Last name:^*

First name:^*

Relationship to the child:^*MotherFatherOther
If other, specify:

Phone number:^*

Email address:^*