Teacher Survey

First I would like to get to know you before we dive in, so please take a few minutes and fill out this survey. By filling out this survey, I can make sure I’m clear on your goals and overall needs in this program. This information is confidential and will NOT be shared.





Years of Classroom Experience:

Grade(s) Currently Teaching:

Student's Name (First name only or pseudonym):

Number of student's older siblings:


Number of younger siblings:


Student's History

State/Country of origin:

Came to this family at age:

Previous Trauma: PhysicalSexualEmotionalPrenatal AlcoholPrenatal DrugsMeth Exposure

Number of moves child has had:

Visits with perpetrator of trauma: NoneIn the PastCurrently

Communication with Parents: NoneLittleExcellent

Cooperation from Parents: NoneLittleExcellent

Current Concerns with this Student:

DietSleepDigestionConstipationAllergiesSensoryDevelopmentAilments (list)

IQ: LowAverageHighVery High

Home behavior concerns (list):

School behavior concerns (list):

Public behavior concerns (list):

Other info you want me to know (list):

Thank you for taking the time to fill this out. I know your time is valuable! This info will help me expedite the course to be the most beneficial to you. I want to be sure I leave no stone unturned in helping you with your quest for success with the children. I know your investment of time and energy during this course will pay big dividends! I believe this program could be a turning point for your family to have lots more love and laughter!

We can make a difference,