I&RS Parent Questionnaire - Kingsway Regional School District

Kingsway Regional High School
Intervention and Referral Services Team
Parent Questionnaire
Confidential
The Intervention and Referral Services Team received a Request for Assistance
regarding your child. Please complete the questionnaire and return to your child’s
Guidance Counselor or John Cappolina. Feel free to add additional information
or leave a question blank.
Please contact John Cappolina, Intervention and Services Team Coordinator, at
856-467-3300 ext. 4272 or via e-mail at cappolinaj@kingsway.k12.nj.us with
any questions or concerns. Thank you for your assistance and cooperation.
1. What are your child’s strengths?
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2. What makes you proud of your child?
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3. What does your child do that causes the most concern?
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4. What has been the most successful way to confront your child’s behavior?
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5. Has your child visited a health professional for any physical or
emotional issue that interfered with their success in school?
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6. How does your child spend their free time? Are they involved in
community activities outside the home?
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7. Does your child share their thoughts and feelings with you or anyone else?
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8. Have there been important changes in the family structure and if so, how did
your child react to these changes?
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9. How can the school assist you with your concerns for your child?
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10. Have you noticed any changes in your child’s social activities, sleeping habits,
or personal hygiene?
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11. Does your child have difficulty with any of the following:
Ability to stay focused on one task at a time
Expressing feelings/emotions/concerns
Getting along with peers/siblings
Telling the truth
Dealing with change
Respect for authority
12. Please any additional information
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