Participant Information

Participant Information

Participant’s Name: ________________________________
(Check box if self)

Describe briefly what you think this participant’s strengths and talents are:

Describe briefly what you think this participant’s weaknesses are:

Check those that accurately describe:

Best Teaching Strategy
____ Auditory
____ Visual
____ Kinesthetic
____ Visual-Kinesthetic
____ Auditory-Visual
____ Auditory-Visual-Kinesthetic

____ Is able to differentiate between his/her left hand
____ Is able to differentiate between his/her right hand
____ Appears to use both right and left sides equally

Motor Coordination and Body Image
____ Has tightly muscled body
____ Has low muscle tone
____ Has average muscle tone
____ Is coordinated and plays in many sports well
____ Has difficulty playing some sports
____ Does not like to be touched
____ Does not seem to be aware of his body in space
____ Pays attention to body cues, knows when hungry, tired and takes care of bodily needs
____ Is skin sensitive and complains at times that clothing is too rough or hurts
____ Compulsively overeats
____ Stumbles and trips, runs into things or knocks things over often

Social and Emotional Adjustment
____ Appears to be appropriately independent, self-reliant, and mature for age
____ Appears to have a positive self-image
____ Can be very hard on him or herself
____ Whines, complains and generally manipulates
____ Is able to get along with others
____ Is direct and can ask for what he/she needs and wants
____ Performance is uneven and marked good and bad days
____ Tires easily
____ Is argumentative and oppositional at times
____ Wants to please
____ Has anxiety exhibited by stomach aches, headaches or other physical symptoms
____ Shows anxiety by chewing on clothing, toys or own body

Observed Behaviors
____ Distracted by internal stimuli
____ Distracted by external stimuli
____ Needs constant reminders to stay on task
____ Needs occasional reminders to stay on task
____ Is easily bored
____ Needs several minutes to process information before acting
____ Needs repetition in order to internalize feedback or instruction
____ Once something is learned can remember to correct his/herself
____ Gives up when frustrated
____ Is determined and keeps trying
Do you have any other comments that would help us better understand the participant?

Signature: ______________________________ Date: ____________________
Relationship to participant: __________________________