Learning Support Request Form

To be completed by parents or guardians.

Please review the form, collect your information and then complete this form in one session. Partial forms will not be saved. Much of the form is optional - you may complete as much as you like - with the understanding that the more information you provide, the more insight we may be able to provide.

This form will be forwarded to your students' teacher or GA to help inform our practice of supportive and inclusive education. You will receive an immediate, automated response to confirm that your form was submitted, along with a copy of the form. Thank you!

Topics covered by the form:
- Contact Information
- Family History
- Educational History
- Medical History
- Development
- Learning Style
Today's Date Today's Date / MM / DD YYYY
What is your primary reason for completing this form? What areas of support are you interested in receiving?
Contact Information
Student's Name Student's Name First Last
Student's Birthdate Student's Birthdate / MM / DD YYYY
Student's Grade
Guardian Email

A copy of the form will be sent to this email address; if you don't get a copy, please check your junk mail.
Guardian Name (person completing this form) Guardian Name (person completing this form) First Last
Guardian Phone Number Guardian Phone Number - ### - ### ####
Where does the student live?

Town or City name.
Support Teacher's Name Support Teacher's Name First Last
If in Grades 10 - 12, please put Grad Teacher
Teacher's Email

A copy of the form will be sent to this email address; if you don't hear from them please email to check in and make sure they got the form.
Who is your Regional Administrator?
Student's Grad Advisor
Family History
How many children do you have and what are their ages?

Example: Jimmy (8), Janice (10)
How long have you been homeschooling? What does a day in your life look like?
If there is a history of challenges or exceptionalities in the family (siblings or guardians) please provide details below.
Educational History
Please list the schools your child has attended:
What made you choose homeschooling? Do you have a specific homeschool philosophy?
Please check any areas in which apply to your student.

Please check any areas in which apply to your student. Gifted (exceptionally athletic, intelligent, creative...) Mental Health concerns (Anxiety, Depression...) Speech concerns Learning difficulties (general) Behaviour (ADD, ADHD, Opposition, Defiance...) Health concerns (Cancer, Diabetes, Epilepsy...) English is not first language Other Other

Please explain "Other"
Has your child been on an IEP (Individualized Education Plan)?

Has your child been on an IEP (Individualized Education Plan)? Yes No Unsure
Please list any previous testing your child has had, with dates and results if possible.

Examples: Psych-ed, SLP, OT, etc.
Please attach copies of any testing or previous IEPs that have taken place.

Attach Files
Medical History
Were there any significant prenatal concerns, major stressors or birth trauma? If applicable, what is the child’s adoption history?
Has your child had any health concerns? If yes, please explain.
When was his/her last eye exam?

Even if your child doesn't wear or seem to need glasses, eye tracking and convergence greatly impacts reading and can be assessed by an optometrist.
When was his/her last hearing test?

If you haven't had a hearing test, contact your public health unit for a free screening. If your child has had ear infections, their hearing may be impacted.
Please check all concerns that apply:

Please check all concerns that apply: ear infections antibiotics used often reactions to vaccinations significant fears/night terrors allergies vision/tracking problems none of the above Other Other
Please explain if any of the above were checked.
Check off any sensitivities your child has:

Check off any sensitivities your child has: touch light smells/tastes tags/clothing hugs sound gag reflex none
Please explain if any of the above were checked.
Describe any unusual stress in his/her life: (a move, parental separation, etc.)
Describe your child's level of daily activity.
Describe your child's eating habits.
Describe your child's bedtime and sleep habits.
Describe your child's screen habits.
Development

Please describe any concerns you have around the following subjects.
Gross Motor - For example, how would you describe their ability to move around, catch objects, bike, balance, etc.? Are graceful, clumsy, bumping into walls?
Did your child crawl, and if so, at what age and for how long?
Fine Motor - How is their printing, handwriting, manipulation of small objects, etc.?
Socialization

Do they make and keep friends easily?
Learning Style
Given the choice, what does your child prefer to do?
Weekly Activities or Hobbies

What are your child's weekly activities or hobbies?
What does your child struggle with?

What does your child struggle with? reading math writing seems to forget things right after learning them can't follow a short list of instructions takes a long time to learn concepts has trouble staying focused and on task disorganized in thoughts/actions anxiety perfectionism socially inappropriate behaviour emotions extreme shyness difficulty with change none of the above Other Other
Preferred Learning Style

Preferred Learning Style active learning (i.e. making models group work - discussions/projects prefers to have lots of parental support informative videos workbooks (written instruction) needs to move while learning likes to work quietly, on his/her own seems to have no interest in learning needs external motivation Other Other
Current helps or adaptations in place:

Please provide examples of any current helps or adaptations that may be in place. Adaptations may include: Scribing, extra time, use of calculators, reading for them, requiring one-on-one, quiet room, visual scheduling, wiggle cushions, movement breaks, management of transitions, repeating instructions, plan for the day, excessive preparation before change/new experiences.
Describe what makes your child special; what are his/her strengths?
Additional Information

Please provide any additional information you think we should have about your child.
Thank you for taking the time to fill in this form. We look forward to working alongside you and your family.

Learning Support Request Form

Learning Support Request Form

Topics covered by the form:

Contact Information

Family History

Educational History

Medical History

Development

Learning Style