Participation Questionnaire

Step 1 of 2

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Child's First Name*
Child's Last Name*
Date of Birth*
Date Format: MM slash DD slash YYYY
Informant*
Relationship*
Skills
The information requested below is designed to help our therapists learn what matters most to you and your child in order to allow us to provide high quality individualized care. If your child is able to help you fill this out, please let them do as much as possible. If they are unable to participate, please fill it out for them.
Thinking about your child's abilities and the things you need or work like them to do (personal care, mobility, ability to navigate the community, homework, chores, school, play):
What would you like your child to be able to do that they aren’t able to now? Please try to list at least 5 things and up to 10 things under skill based on your concerns.
After listing all skills in a section, under ‘Importance‘ please rate how important you feel that skill is on a scale from 1 – 10 where 10 is the most important and 1 is the least important. You may rank multiple skills the same number for importance.
Now, under ‘performance,’ please rate how you feel your child performs each of these skills on a scale from 1 – 10 where 1 indicates they can’t do it at all and 10 indicates they does it as best possible.
Last, under ‘satisfaction,’ lease rate your satisfaction with your child’s performance of each skill on a scale from 1 – 10 where 1 indicates you are not satisfied at all with their performance and 10 indicates you are very pleased with his performance
Skill 1*
Importance*
Please enter a number from 1 to 10.
Performance*
Please enter a number from 1 to 10.
Satisfaction*
Please enter a number from 1 to 10.
Best Possible Performance - Skill 1*
Please describe what you and/or your child sees as being their best possible performance of this skill:
Skill 2*
Importance*
Please enter a number from 1 to 10.
Performance*
Please enter a number from 1 to 10.
Satisfaction*
Please enter a number from 1 to 10.
Best Possible Performance - Skill 2*
Please describe what you and/or your child sees as being their best possible performance of this skill:
Skill 3*
Importance*
Please enter a number from 1 to 10.
Performance*
Please enter a number from 1 to 10.
Satisfaction*
Please enter a number from 1 to 10.
Best Possible Performance - Skill 3*
Please describe what you and/or your child sees as being their best possible performance of this skill:
Skill 4*
Importance*
Please enter a number from 1 to 10.
Performance*
Please enter a number from 1 to 10.
Satisfaction*
Please enter a number from 1 to 10.
Best Possible Performance - Skill 4*
Please describe what you and/or your child sees as being their best possible performance of this skill:
Skill 5*
Importance*
Please enter a number from 1 to 10.
Performance*
Please enter a number from 1 to 10.
Satisfaction*
Please enter a number from 1 to 10.
Best Possible Performance - Skill 5*
Please describe what you and/or your child sees as being their best possible performance of this skill:

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