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Intake Questionnaire for Parent/Guardian
Intake Questionnaire for Parent/Guardian

* indicates a required field.

Personal Information

Today's Date:
Your Full Name:*
Student's Name:*
Your Relationship to the Student:*
What is your permanent address?*
What is the phone number where we can most easily reach you?*
What email address do you prefer we use if we need to email you?*

Student's Educational Information

How were your student's classes structured in High school (ex. Small groups, regular classes, individual instruction)?*
Did your student receive any support services or accommodations in High School? If so, please explain.*
What comes easy for your student academically? *
What does your student struggle with academically? *
Has your student declared a major at RIT? If so, what is it? If not, what are they considering?
Do you know why your student chose this major?
What is your student's dream job?

Student's Work Experience

Has your student ever worked? Yes No
If so, where?
What were the responsibilities that this job entailed?
Did your student meet expectations?
Did your student have any specific challenges at this job?

Student's Treatment/Medical Information

What is your student's diagnosed disability?*
When was your student diagnosed?*
When was the last assessment done?*
By whom?
If you were to describe your student's diagnosis and how it affects you and your family, what would you say?*
Is your student currently working with a therapist?* Yes No
If so, what is the therapists name?
Aside from your student's therapist, does your student meet with other medical professionals on a regular basis?* Yes No
Will your student continue to work with his/her therapist while at RIT?
Yes No
If so, how often will your student meet with/talk to him/her?
What medications is your student currently taking?*
Currently, how is the medication administered? (ex. provided by parent, student uses pill box, etc.)
Please describe any side effects your student experienced associated with these medications.
How will your student obtain your medications while at RIT?

Student's Housing/Living

Describe your student's current living arrangements (for example, has own room, shares room, etc.)*
Describe your student's living habits (i.e. privacy needs, orderliness, etc,.)*

Student's Stress Management

What particular situations trigger a stress response in your student?*
How does your student cope when he/she gets very afraid?*
How does your student cope when he/she gets very anxious?*
How does your student cope when he/she gets very frustrated?*

Student's Social Interaction

Tell us a little bit about your student's relationships with other people. (ex. friends, teachers, family)*
What are some common social challenges for your student?*
At the end of the day, how does your student unwind?*
What does your student do to have fun?*

Transition/Success at RIT

What are you most worried about in terms of your student's adjustment/success at RIT?*
How has your student prepared for success at RIT? *
Any additional information you wish to share:

Thank You. We Look Forward to Working with Your Student!

One of more required pieces of information has been left blank. Please review the form and enter required information and then submit the form.

Laurie Ackles
Spectrum Support Program
Rochester Institute of Technology

PHONE: (585) 475-6936
FAX: (585) 475-5832
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