BASE Program Parent/Guardian Questionnaire

Please complete this form as thoroughly and honestly as possible to allow us to get to know your student and begin to understand the scope of supports that will help your student be successful in the college environment.

General Information

Student's name(Required)

First Last

Has your student been accepted to BC?(Required)

yes

no

Family Information

Please provide information for parents/guardians and siblings.(Required)

click the + sign to add additional family members

Name of family member

Relationship to student

Does this family member reside in the same household as the student? full-time, part-time, not at all

 

Add Remove

Disability-related Information

What is your student’s diagnosed disability(ies)?(Required)

At what age was your student diagnosed?(Required)

Is your student currently working with a therapist (behavior, speech, etc.) and/or with a mental health provider?(Required)

yes

no

If yes, in what type of therapy is your student currently involved?

What arrangements have you made to continue your student’s therapy while attending BC?

Does your student take daily medication?(Required)

yes

no

If yes, is the student able to take it without reminders from you or other adults?

Most of the timeOccasionallyRarelyNever

Academic Information

In your opinion, what high school accommodations, if any, were most helpful to your student?(Required)

Based on your observation and experience:

Does your student independently (without reminders or assistance) maintain an assignment book/list or calendar of due dates?(Required)

Most of the time

Occasionally

Rarely

Never

Does your student independently (without reminders or assistance) complete out-of-school assignments or projects?(Required)

Most of the time

Occasionally

Rarely

Never

Does your student independently (without reminders or assistance) prepare for exams?(Required)

Most of the time

Occasionally

Rarely

Never

Does your student independently (without reminders or assistance) complete writing assignments (essay/term papers)?(Required)

Most of the time

Occasionally

Rarely

Never

Does your student independently (without reminders or assistance) communicate with teachers and other school support personnel about problems or concerns?(Required)

Most of the time

Occasionally

Rarely

Never

Daily Living Information

Does your student independently (without reminders or assistance) maintain a good sleep schedule?(Required)

Most of the time

Occasionally

Rarely

Never

Does your student independently (without reminders or assistance) attend to personal hygiene tasks (showering, combing hair, brushing teeth)?(Required)

Most of the time

Occasionally

Rarely

Never

Does your student independently (without reminders or assistance) do their laundry?(Required)

Most of the time

Occasionally

Rarely

Never

Does your student independently (without reminders or assistance) clean their bedroom?(Required)

Most of the time

Occasionally

Rarely

Never

Does your student independently (without reminders or assistance) implement self-calming/destress strategies, when needed?(Required)

Most of the time

Occasionally

Rarely

Never

What do you hope that your student will get from participating in this program?(Required)

How did you hear about the BASE Program?(Required)

Name of individual completing this form(Required)

First Last

Mobile phone of individual completing this form(Required)

Email address of person completing this form (for ongoing correspondence, if necessary):(Required)

Date

MM slash DD slash YYYY

Phone

This field is for validation purposes and should be left unchanged.