Teacher Questionnaire

Email

This field is for validation purposes and should be left unchanged.

Please answer the following questions based on your direct observations of the student. You are not expected to make a diagnosis or clinical judgement.

The information you provide may be shared with the student's parent or guardian. Please avoid including the names or identifying details of other students.

Required fields are marked with an asterisk.

Student details

Student's first name*

Student's surname*

Preferred name

Leave blank if this is the same as their first name.

Date of birth*

School or early learning service*

Year level, class or group*

Subject or learning area you teach

Complete this field if you only work with the student in particular subjects or settings.

Your details

Your full name*

First Last

Your role or position*

Work email address*

Phone number

How long have you known the student?*

How often do you work directly with the student?*

Most school days

Several times a week

About once a week

Less than once a week

Current concerns

Please describe the concerns using specific observations where possible.

Please briefly describe the main concerns or difficulties you have observed.*

When did you first notice these concerns?*

When or where are these difficulties most noticeable?

Consider particular subjects, activities, times of day, social settings or transitions.

What strategies or supports appear to help?

Are there situations that make the difficulties more noticeable?

To your knowledge, has the student previously received an assessment, intervention or additional support for these concerns?*

Yes

No

Unsure

Please provide any relevant details.

Has the student experienced extended absences or significant disruptions to their learning?*

Yes

No

Unsure

Please provide any relevant details.

Learning, attention and organisation

Rate each area based on what you typically observe in the educational setting.

How much difficulty does the student typically experience in the following areas?*

Select one response for each row. Choose “Not observed or unsure” where you do not have enough information.

	No difficulty observed	Mild difficulty	Moderate difficulty	Significant difficulty	Not observed or unsure
Remembering recently provided information or instructions
Sustaining attention during lessons or activities
Ignoring surrounding distractions
Following multi-step instructions
Starting tasks without repeated prompting
Completing tasks within expected timeframes
Organising tasks, materials or belongings
Keeping track of required items
Moving between activities, classrooms or routines
Learning and applying new concepts
Decoding unfamiliar words
Understanding what they have read
Spelling
Expressing ideas in writing
Handwriting
Typing or completing work digitally
Understanding spoken language
Expressing themselves clearly

Please provide examples or additional context.

Behaviour and self-regulation

Rate how often you observe each behaviour.

How often do you observe the following behaviours?*

Select one response for each row. Choose “Unsure or not applicable” where appropriate.

	Not observed	Occasionally	Often	Very often	Unsure or not applicable
Avoids or refuses tasks they find difficult
Requires frequent prompting to remain engaged
Disrupts their own learning or the learning of others
Acts without considering the likely outcome
Fidgets or has difficulty remaining seated when expected
Talks excessively or calls out during class
Interrupts others or has difficulty waiting their turn
Becomes involved in frequent arguments with peers or adults
Becomes physically aggressive towards others
Damages other people's belongings or school property
Engages in self-injurious behaviour
Engages in repetitive movements or behaviours
Becomes distressed when routines or expectations change

Please provide examples or additional context.

Important: This form is not monitored for urgent concerns. Where there is an immediate concern about the student's safety or the safety of others, please follow your organisation's safeguarding and emergency procedures.

Social interaction

Rate each area based on the student's typical interactions with peers and adults.

How much difficulty does the student typically experience in the following areas?*

Select one response for each row. Choose “Not observed or unsure” where you do not have enough information.

	No difficulty observed	Mild difficulty	Moderate difficulty	Significant difficulty	Not observed or unsure
Joining group activities
Responding when other students approach them
Initiating interactions with other students
Taking turns and sharing
Making friends
Maintaining friendships
Understanding social cues
Recognising other people's feelings or perspectives
Respecting other people's boundaries and belongings
Resolving disagreements or conflict
Participating appropriately in cooperative activities

Does the student have at least one positive peer relationship?*

Yes

No

Unsure

Please provide examples or additional context.

Emotional wellbeing

Rate how often you observe each response or behaviour.

How often do you observe the following?*

Select one response for each row. Choose “Unsure or not applicable” where appropriate.

	Not observed	Occasionally	Often	Very often	Unsure or not applicable
Becomes distressed after making a mistake
Becomes frustrated by challenging work
Worries excessively or frequently seeks reassurance
Becomes angry or irritated quickly
Has difficulty calming after becoming upset
Is highly self-critical
Shows noticeable or rapid changes in mood
Becomes emotionally overwhelmed or dysregulated
Becomes distressed when routines change
Appears withdrawn or avoids participation due to shyness or anxiety
Experiences distress when separating from a parent or caregiver

Please provide examples or additional context.

Strengths and current support

What are the student's strengths and interests?*

Consider learning, creativity, relationships, communication, practical skills, motivation and activities they enjoy.

What helps the student engage, learn or regulate their emotions successfully?*

What adjustments or supports are currently being provided?

Which areas do you believe currently require the most support?

Has the school or educator discussed these concerns with the student's parent or guardian?*

Yes

No

Unsure

Please provide any relevant details.

Is there anything else that would help us understand or support this student?

For teachers and educators

Parents and carers

Teachers and educators

Student details

Your details

Current concerns

Learning, attention and organisation

Behaviour and self-regulation

Social interaction

Emotional wellbeing

Strengths and current support