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Parent Questionnaire for ASI Program Participants

The purpose of this questionnaire is to help parents identify, observe and document areas of change for students who have participated in & completed ASI’s brain-training programs. The simple questionnaire below will help you identify your child’s relative strengths and weaknesses in important areas of intellectual and social functioning.

 
Student's Information

Student's First Name :
 

Student's Last Name :
 

Parent's Information

Observing Parent's First Name :
 

Observing Parent's Last Name :
 

Observation Checklist

For each of the following statements, choose a response that best reflects the frequency of your child’s performance of each activity. Rate your child’s performance using one of these three responses: most of the time; occasionally; or seldom.

Retains information learned through reading. :
 

Confuses words when speaking. :
 

Has difficulty remembering spoken directions. :
 

Retains information when spoken to. :
 

Has difficulty starting assigned work. :
 

Has difficulty staying focused on a task. :
 

Is able to plan and organize homework or work
assignments. :
 

Easily learns new information/things. :
 

Is able to recall previously learned information. :
 

Is having difficulties learning. :
 

Gets work assignments done on time. :
 

When speaking, sequences words in proper sentence order. :
 

Has difficulties pronouncing words. :
 

Has difficulty recognizing familiar words when reading. :
 

Printing/writing is difficult to read. :
 

Has difficulty concentrating when reading. :
 

Reverses letters or words when printing or writing words. :
 

Has difficulty printing/writing letters of the alphabet. :
 

When listening, does not understand familiar word meanings appropriate to his/her age. :
 

Is confident about self. :
 

Is easily frustrated. :
 

Is impulsive. :
 

Is irritable or angry. :
 

Has episodes of explosive and/or unpredictable behavior. :
 

Makes careless mistakes. :
 


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