Literacy Care Teacher Questionnaire

Thank you for taking the time to complete these questions. This child has been referred for a specialist opinion of their developmental learning and literacy problems. Your contribution is very important and I appreciate that your time is valuable.

In addition to providing information about this child’s academic and scholastic progress, the questions provide an opportunity for you to identify any concerns you may have and indicate where consultation with other professionals may assist you.

Please return this questionnaire to the child’s parents before the initial consultation. This form can also be downloaded from on the CDN website ( https://cd.net.au)

Child Information

Child's SURNAME

Child's FIRST NAME

Gender

MaleFemaleOther

Child's Grade

Teacher and School Information

Your Name

Your Position

School

Learning Support Teacher

Guidance Officer or Equivalent

How long have you known this child?

Date of completing this questionnaire

Strengths / Interests / Concerns

What is this child’s specific strengths and interests, and what do they enjoy?

Please elaborate on any concerns you have identified

Learning Support and Educational Adjustments

Does the child have a Personalized Learning Plan or equivalent?

YesNo

Has the child been given an NCCD category?

PhysicalCognitiveSensitive Social-Emotional

If the child does not have a Personalized Learning Plan, is there any other form of learning support provided in the classroom? Please briefly describe.

Does the child use Assistive Technology?

YesNo

If yes, please briefly explain

Video Conference and Additional Information

Would you agree to a video conference with clinicians from Literacy Care and the Child Development Network if requested by parents?

YesNo

Do you have any additional comments or questions?

Please provide this child’s parents or guardians with copies of any assessment reports, or any other written information that may be of assistance.

Thank you!