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Educational Assessment Page

Please use the links below to fill out the assessment page.  After completing the page, please click on the submit button and we will review the information and contact you as soon as possible.

Contents

Contact Information
School Name
Educational Materials
1st Child's Name
2nd Child's Name
3rd Child's Name
1st Child's Grade Level
2nd Child's Grade Level
3rd Child's Grade Level
1st Child's Reading Level
2nd Child's Reading Level
3rd Childs Reading Level
1st Child's Comprehension Level
2nd Child's Comprehension Level
3rd Child's Comprehension Level
1st Child's Spelling Skills
2nd Child's Spelling Skills
3rd Child's Spelling Skills
1st Child's Math Skills
2nd Child's Math Skills
3rd Child's Math Skills
Does your 1st child have good study habits
Does your 2nd child have good study habits
Does your 3rd child have good study habits
What subject does your 1st child like best
What subject does your second child like best
What subject does your 3rd child like best
On a scale of 1 to 5 how inquisitive is your 1st child
On a scale of 1 to 5 how inquisitive is your 2nd child
On a scale of 1 to 5 how inquisitive is your 3rd child
Do you require a study schedule and undisturbed study area for your 1st child
Do you require a study schedule and undisturbed study area for your 2nd child
Do you require a study schedule and undisturbed study area for your 3rd child
What type of educational materials do you have at home
Does you child or children have a current library card
If yes, how often do you go to the local library
If no, why not
What type of educational materials do you have at home
What educational level would you like your children to reach
Has your child or children expressed a desire for pursuing a certain career
If yes what career
How many hours a day does your 1st child spend watching TV or playing Video Games
How many hours a day does your 2nd child spend watching TV or playing Video Games
How many hours a day does your 3rd child spend watching TV or playing Video Games
How many hours does your 1st child spend reading, not including homework
How many hours a day does your 2nd child spend reading, not including homework
How many hours a day does your 3rd child spend reading, not including homework
On a scale of 1 to 5 how would you rate your involvement in your children's educational development
This statement is for the consultant, please skip until the consultant has reviewed the assessment
After the consultation, what is your decision

Please explain your decision

Please provide the following Contact Information:

      First Name 
       Last Name 
  Middle Initial 
           Title 
    Organization 
  Street Address 
 Address (cont.) 
            City 
  State/Province 
 Zip/Postal Code 
         Country 
      Work Phone 
      Home Phone 
             FAX 
          E-mail 

Enter your child's school name ... in the space provided below.

Enter your educational materials... in the space provided below.

Enter your 1st child's name

      First Name 
       Last Name 
  Middle Initial 
             Age 
             Sex Male Female

2nd child's name

      First Name 
       Last Name 
  Middle Initial 
             Age 
             Sex Male Female

3rd child's name

      First Name 
       Last Name 
  Middle Initial 
             Age 
             Sex Male Female

Enter your 1st child's grade level ... in the space provided below.

Enter your 2nd child's grade level ... in the space provided below.

Enter your 3rd child's grade level ... in the space provided below.

How is your child's reading level?

Good Average Fair Poor

How is your 2nd child's reading level?

Good Average Fair Poor

How is your 3rd child's reading level?

Good Average Fair Poor

How is your child's comprehension level?

Good Average Fair Poor

How is your 2nd child's comprehension level?

Good Average Fair Poor

How is your 3rd child's comprehension level?

Good Average Fair Poor

How is your child's spelling ability?

Good Average Fair Poor

How is your 2nd child's spelling ability?

Good Average Fair Poor

Your 3rd child's spelling ability?

Good Average Fair Poor

Your 1st child's math skills?

Good Average Fair Poor

Your 2nd child's math skills?

Good Average Fair Poor

Your 3rd child's math skills?

Good Average Fair Poor

Does your 1st child have good study habits?

Yes No

Does your 2nd child have good study skills?

Yes No

Does your 3rd child have good study skills?

Yes No

My 1st child like the following subject best.

My 2nd child like the following subject best.

My 3nd child like the following subject best.

On a scale of 1-5 how inquisitive is your 1st child?

On a scale of 1-5 how inquisitive is your 2nd child?

On a scale of 1-5 how inquisitive is your 3rd child?

As a parent do your require a study schedule and undisturbed study area?

Yes No

As a parent do you require a study schedule and undisturbed study area for your 2nd child?

Yes No

As a parent do your require a study schedule and undisturbed study area for your 3rd child?

Yes No

Does you child or children have a current library card?

Yes No

If yes, how often do you go to your local library?

Weekly Monthly Bi-Weekly As Needed

If no, why not?

What type of educational materials do you currently have in your home library?

Reading Programs                

Atlas                           

Dictionary                      

Computer and Computer Software

Math Programs                   

Literature Books                

Reference and Encyclopedia      

Science

Thesaurus                       

Educational Videos, DVD's                       

Computer Software                       

Educational magzines                       

What educational level would you like for your children to reach?

Middle School
High School
College
Graduate School

Has your child expressed a desire for pursuing a certain career?

Yes No

If yes, what career?

How many hours a day does your child watch TV or play video games?

How many hours a day does your 2nd child watch TV or play Video games?

How many times does your 3rd child watch TV or play Video games?

How many hours a day does your child read, not including homework?

How many hours a day does your 2nd child read, not including homework?

How many hours a day does your 3rd child read, not including homework?

On a scale of 1 - 5 how would you rate your involvement in your child's educational development?

Consultant recommends the following program for your child/children

Does the parent agree?

Yes No

If parent does not agree, please give the reason for your decision.

Bill Davis Copyright © 2004 Discountutor.com All rights reserved.
Revised: 07/08/04