CIP Application Portal » Parent Questionnaire Form

Full Year
Summer@CIP
SummerSessions@CIP (Virtual)

Has lived away from home for more than 6 months successfully on their own
Has lived away from home for than 6 months but had regular residential support
Has experience living away from home only a few weeks at a time and would need support and regular check-ins
Has never lived away from home before

Has lived with roommate(s), formed positive relationships and advocated for themself when necessary.
Has lived with roommate(s) but has struggled at times to communicate/advocate for themself.
Has lived with roommate(s), but tended to isolate themself
Has never lived with roommate(s) before

Neat and doesn’t feel anxiety if something is out of order
Neat but does feel anxiety if something is out of order
Messy but has help from parent/advisor regularly to clean space
Messy and always keeps the space this way

Can cook a well-balanced meal on their own and can follow a moderately difficult recipe
Has some cooking experience, but needs some assistance in making healthy choices
Can “boil water and make toast” and will need assistance in preparing a full, well-balanced meal and with following recipes
Has never cooked before so he/she will need regular assistance

Has gone to store on their own and used a shopping list successfully
Has gone to the store on their own but usually returns with several items missing
Usually goes with a parent who assists with shopping
Not used to going to the store on their own

Always has a well balanced meal with plenty of fruits and veggies
Makes good choices but doesn’t always eat enough fruits and veggies
Eats healthy foods but has a restricted range of food he/she will eat
Prefers a diet of convenience foods, soda, and starches

Can load washer and dryer correctly, use proper settings, fold and put laundry away with no assistance
Can perform tasks listed in A (above), but needs some assistance
Has done laundry a few times on their own but needs regular supervision
Has never done his/her own laundry

Always manages these tasks independently with no help
Occasionally needs a prompt but most of the time handle these tasks on their own
Occasionally needs a prompt and sometimes resists taking care of these tasks
Regularly needs a prompt and assistance

Always looks good
Sometimes looks groomed
Sometimes looks groomed but needs prompts
Usually unkempt (wrinkled shirts, messy hair, body odor, etc)

Regularly sets own alarm and gets up on time
Hits snooze but is usually out the door on time
Is usually running late
Needs extensive prompts to get out of bed

Has successfully maintained a checking account on their own for at least 1 year with no issues
Has maintained a checking account but needs assistance with balancing and reconciliation
Has a checking account but has regular assistance in managing their funds
Has never maintained a checking account

Has used a credit card for at least 1 year with no outstanding balances and no issues
Has a card but does not comprehend spending limits
Had a card but no longer has one due to negligence
Has never had a card or is not ready for a card for one at this time

Has their own license and a clean driving record for at least a year
Just passed the driver’s test or has permit
Is interested in learning
Not yet ready for this step or may not obtain due to safety issues

Has used it regularly on their own and is confident finding their way around
Has used it before but not on their own
Has used it before but did not have a positive experience and felt anxious
Has not used it before

They have several friends and meet with them regularly for social activities
They have a couple of friends at school but do not see them regularly outside of school
They perceive others as friends but the friendship is not reciprocated
They prefer to be alone and stay to themself

The student initiates activities with their peers
The student sometimes initiates activities with their peers
Their friends typically initiate the activity
The parent typically initiates the activity

All of the time
Most of the time
Occasionally
Never

Engages in several activities a week
Engages in at least one activity each week
May engage in an activity monthly
Rarely will engage in social activity

Knows exactly what degree or career he/she wants
Would like to go to college, but is not sure of a major or degree
Is not sure about college, but would like to try it out
Is not quite ready for college at this time but would like to try it in the future
N/A Does not apply to my student-vocational track only

Yes, and He/She did quite well
Yes, overall it was a positive experience but he/she had some challenges
Yes, but it was not a positive experience for the student
No, the student has never taken a college class before
N/A Does not apply to my student-vocational track only

Totally independent and has succeeded in the past with organizing their own assignments and managing his/her own time
Needs small amounts of assistance in getting started or in organizing their time, but once they get going, can work independently
Needs moderate assistance to organize their academic work and is more successful when checking in with someone on a regular basis
Needs a high level of assistance where a teacher or parent can break down assignments into smaller chunks to help them decide what to do and when to do it

Works well independently and will not need tutorial/study hall assistance
May need some assistance periodically (1-2 hours of tutorial/study hall per week)
Will need to meet with a tutor or have study halls regularly (3-4 hours per week)
Will need as much time as possible with a tutor or in study halls (5+hours per week)

Feels very comfortable speaking with and seeking assistance from their teacher/supervisor and has formed close relationships in the past
Seeks assistance / clarification from the teacher/supervisor but tends to shy away from regular contact
Sought Assistance / clarification in the past but did need encouragement from a tutor or parent to follow through
Does not feel comfortable speaking with teachers/supervisors and will need help in learning to approach them

Has successfully maintained a position for more the 6 months
Has tried working but resigned
Has tried working but was discharged/released by supervisor
Has no employment/internship experience

Will not need assistance
May need instruction from vocational class but will not need a job coach
Needs occasional assistance from job coach (1x per month)
Needs regular assistance from a job coach (weekly)

No
Over 3 years ago but it has not been an issue again
1-2 years ago but it has not been an issue again
Within the last year

Clearly knows and understands diagnosis
Accepts diagnosis and has does expresses interest in learning more
Accepts diagnosis but does not clearly understand what it means
Has not fully accepted the diagnosis and feels it is best to not discuss it

Never
Sometimes-when needed
Regularly-biweekly or monthly
Frequently-weekly or more than once a week

A helpful, positive experience
Reluctant to go at first but he/she found it helpful
Reluctant to go and he/she found it unhelpful
Does not like to attend

No
Yes-over 3 years ago but has been stable since
Yes-1-3 years ago but has been stable since
Yes-within last year

Has always been stable
Has been stable the last three years
Has been stable the last year
Is not presently stable

No
Yes, for reasons unrelated to learning difference (allergies, acne, etc.)
Yes, to help with focus, attention (ADHD, ADD), or for slight anxiety
Yes, for more extensive anxiety or depression

Takes medication regularly without any prompts
Takes medication with occasional prompts
Takes medication with regular prompts
Needs daily assistance in taking medication or possibly does not want to take
N/A Does not apply to student-is not prescribed medication

No
Over 3 years ago but it has not been an issue again
One time within last three years but it has not been an issue again

Yes, he/she can use constructive criticism in a positive way
He/she accepts feedback but has difficulty interpreting suggestions
He/she has difficulty accepting constructive criticism and usually does not learn from what is said
He/she gets upset when given constructive criticism and may get angry or walk out

No tolerance
If used recreationally in a safe environment and of legal age, it's ok
May have tried in the past but not within the last year
Has used regularly before and may still be

No tolerance
If used recreationally in a safe environment, its ok.
May have tried in the past but not within the last year
Has used regularly before and may still

Parent Questionnaire Form

Step 1 of 4

Independent Living Section

Social Skills Section

ACADEMIC/VOCATIONAL SECTION

Classroom Skills:

Clinical Section

Contact Us