WESTBROOK SCHOOL DEPARTMENT Social Skills Questionnaire Kindergarten Registration 2016 - 2017

CHILD’S NAME______________________________________________M

F

SCHOOL ATTENDING ___________________________________________________ DATE OF BIRTH _____________________COMPLETED BY___________________________ LIVES W ITH________________________________________________________________________ SIBLINGS __________________________________________________________________________ _____________________________________________________________________________________ Please answer the questions on this form the best that you can. This questionnaire will be confidential and your responses will be shared only with professional personnel. DOES YOUR CHILD: W HERE?

YES

NO

Attend Pre-School or Daycare? If yes, Where?

____

____

Have regular playmates the same age?

____

____

Difficulty getting along with others?

____

____

Have to deal with family stress, multiple moves, illness, separation, divorce, or death?

____

____

Spend time in more than 1 household?

____

____

How does your child spend his/her time? How much TV or video games does your child play every day? How do you manage behavior at home? Do you have any social, emotional, or behavioral concerns about your child? What would you like us to know about your family?