1. Student Name, Birthdate, and Grade
2. Parent/Guardian completing questionnaire
3. Does your child follow a consistent morning routine?
4. Does your child wake up easily on school days?
5. Do you need to assist your child in getting up?
6. Is you child alert and ready for school within a half hour of waking up?
7. How long has your child been following a consistent routine?
8. Does your child's morning routine change on the weekends, holidays, and school break times?
9. Does your child follow a consistent morning routine?
10. Does your child get to sleep easily on school nights?
11. Does your child stay up late often?
12. How long has your child been following this consistent routine?
13. Does your child's bedtime routine change on weekends, holidays, and school break times?
14. Has a teacher ever told you that your child falls asleep in class?
15. If it were up to your child, around what time would he/she choose to go to bed and wake up?
16. Self-Regulation capacities are used to cue or direct how we take in information (perception); how we feel, how we think, and how we act. The direction of self-regulation in each of these domains can vary greatly, so we need to be clear about whether there are differences in how your child regulates perception, emotion, thought, or action. The questions that follow are designed to understand your child's self-regulation capacities related to him/herself, others, the environment, and school work.

PERCEIVE

1. Compared to children the same age, tell me about your child's ability to know when to become aware of, or tune into, sensations and perceptions from different sources (e.g., sights, sounds, inner sensations).
2. Does this capacity vary depending on whether your child is dealing with sensations, feelings, thoughts, or actions? If yes, please explain.
3. Does this capacity vary depending on whether the sensations, feelings, thoughts, or actions involve just your child, other people, the environment, school work? If yes, please explain.

FOCUS/SELECT

1. Compared to children the same age, tell me about your child's ability to know when to pay attention or concentrate and what to pay attention to or concentrate on.
2. Does this capacity vary depending on whether your child is dealing with sensations, feelings, thoughts, or actions? If yes, please explain.
3. Does this capacity vary depending on whether the sensations, feelings, thoughts, or actions involve just your child, other people, the environment, school work? If yes, please explain.

INITIATE

1. Compared to children the same age, tell me about your child's ability to know when to take initiative.
2. Does this capacity vary depending on whether the sensations, feelings, thoughts, or actions involve just your child, other people, the environment, school work? If yes, please explain.
3. Does this capacity vary depending on whether the sensations, feelings, thoughts, or actions involve just your child, other people, the environment, school work? If yes, please explain.

MODULATE

1. Compared to children the same age, tell me about your child's ability to know when to regulate the intensity with which he/she experiences things.
2. Does this capacity vary depending on whether your child is dealing with sensations, feelings, thoughts or actions? If yes, please explain.
3. Does this capacity vary depending on whether the sensations, feelings, thoughts, or actions involve just your child, other people, the environment, school work? If yes, please explain.

GUAGE

1. Compared to children the same age, tell me about your child's ability to know when it's necessary to figure out, or "size up", what is required to get things done.
2. Does this capacity vary depending on whether your child is dealing with sensations, feelings, thoughts, or actions? If yes, please explain.
3. Does this capacity vary depending on whether the sensations, feelings, thoughts, or actions involve just your child, other people, the environment, school work? If yes, please explain.

SUSTAIN

1. Compared to children the same age, tell me about your child's ability to know when and how long to sustain attention.
2. Does this capacity vary depending on whether your child is dealing with sensations, feelings, thoughts, or actions? If yes, please explain.
3. Does this capacity vary depending on whether the sensations, feelings, thoughts, or actions involve just your child, other people, the environment, school work? If yes, please explain.

MODULATE

1. Compared to children the same age, tell me about your child's ability to know when to regulate the intensity with which he/she experiences things.
2. Does this capacity vary depending on whether your child is dealing with sensations, feelings, thoughts, or actions? If yes, please explain.
3. Does this capacity vary depending on whether the sensations, feelings, thoughts, or actions involve just your child, other people, the environment, school work? If yes, please explain.

INHIBIT

1. Compared to children the same age, tell me about your child's ability to know when to resist urges (e.g., not blurt out comments, not do things they've been asked not to do).
2. Does this capacity vary depending on whether your child is dealing with sensations, feelings, thoughts, or actions? If so, please explain.
3. Does this capacity vary depending on whether the sensations, feelings, thoughts, or actions involve just your child, other people, the environment, school work? If yes, please explain.

FLEXIBLE/SHIFT

1. Compared to children the same age, tell me about your child's ability to know when it's necessary to be flexible about or adjust to situations.
2. Does this capacity vary depending on whether your child is dealing with sensations, feelings, thoughts, or actions? If so, please explain.
3. Does this capacity vary depending on whether the sensations, feelings, thoughts, or actions involve just your child, other people, the environment, school work? If yes, please explain.

STOP/INTERRUPT

1. Compared to children the same age, tell me about your child's ability to stop or interrupt him/herself when he/she is already doing something.
2. Does this capacity vary depending on whether your child is dealing with sensations, feelings, thoughts, or actions? If so, please explain.
3. Does this capacity vary depending on whether the sensations, feelings, thoughts, or actions involve just your child, other people, the environment, school work? If yes, please explain.

MANIPULATE

1. Compared to children the same age, tell me about your child's ability to know when it's important to work with information that is being held in mind, for example doing math calculations in his/her head with numbers he/she was told to remember.
2. Does this capacity vary depending on whether your child is dealing with sensations, feelings, thoughts, or actions? If yes, please explain.
3. Does this capacity vary depending on whether the sensations, feelings, thoughts, or actions involve just your child, other people, the environment, school work? If yes, please explain.

ORGANIZE

1. Compared to children the same age, tell me about your child's ability to know when to organize things and what to organize.
2. Does this capacity vary depending on whether your child is dealing with sensations, feelings, thoughts, or actions? If yes, please explain.
3. Does this capacity vary depending on whether the sensations, feelings, thoughts, or actions involve just your child, other people, the environment, school work? If yes, please explain.

HOLD

1. Compared to children the same age, tell me about your child's ability to know when to hold information in mind for later use.
2. Does this ability vary depending on whether your child is dealing with sensations, feelings, thoughts, or actions? If yes, please explain.
3. Does this capacity vary depending on whether the sensations, feelings, thoughts, or actions involve just your child, other people, the environment, school work? If yes, please explain.

FORESEE/PLAN

1. Compared to children the same age, tell me about your child's ability to know when to plan for or anticipate situations.
2. Does this ability vary depending on whether your child is dealing with sensations, feelings, thoughts, or actions? If yes, please explain.
3. Does this capacity vary depending on whether the sensations, feelings, thoughts, or actions involve just your child, other people, the environment, school work? If yes, please explain.

ASSOCIATE

1. Compared to children the same age, tell me about your child's ability to know when to make associations between things to solve problems.
2. Does this ability vary depending on whether your child is dealing with sensations, feelings, thoughts, or actions? If so, please explain.
3. Does this capacity vary depending on whether the sensations, feelings, thoughts, or actions involve just your child, other people, the environment, school work? If yes, please explain.

GENERATE

1. Compared to children the same age, tell me about your child's ability to know when to try to problem solve or reason about things.
2. Does this ability vary depending on whether your child is dealing with sensations, feelings, thoughts, or actions? If yes, please explain.
3. Does this capacity vary depending on whether the sensations, feelings, thoughts, or actions involve just your child, other people, the environment, school work? If yes, please explain.

BALANCE

1. Compared to children the same age, tell me about your child's ability to know when to balance the big picture with the details, or when to shift between focusing on the big picture and focusing on the details.
2. Does this ability vary depending on whether your child is dealing with sensations, feelings, thoughts, or actions? If yes, please explain.
3. Does this capacity vary depending on whether the sensations, feelings, thoughts, or actions involve just your child, other people, the environment, school work? If yes, please explain.

STORE

1. Compared to children the same age, tell me about your child's ability to know when something is important enough that it should be stored in memory.
2. Does this ability vary depending on whether your child is dealing with sensations, feelings, thoughts, or actions? If yes, please explain.
3. Does this capacity vary depending on whether the sensations, feelings, thoughts, or actions involve just your child, other people, the environment, school work? If yes, please explain.

RETRIEVE

1. Compared to children the same age, tell me about your child's ability to know when information should be recalled from memory and what information should be recalled.
2. Does this ability vary depending on whether your child is dealing with sensations, feelings, thoughts, or actions? If yes, please explain.
3. Does this capacity vary depending on whether the sensations, feelings, thoughts, or actions involve just your child, other people, the environment, school work? If yes, please explain.

PACE

1. Compared to children the same age, tell me about your child's ability to know when to maintain or when to adjust the pace of doing things.
2. Does the ability vary depending on whether your child is dealing with sensations, feelings, thoughts, or actions? If yes, please explain,
3. Does this capacity vary depending on whether the sensations, feelings, thoughts, or actions involve just your child, other people, the environment, school work? If yes, please explain.

TIME

1. Compared to children the same age, tell me about your child's ability to know when to check the time or note or estimate how much time has passed.
2. Does this ability vary depending on whether your child is dealing with sensations, feelings, thoughts, or actions? If yes, please explain.
3. Does this capacity vary depending on whether the sensations, feelings, thoughts, or actions involve just your child, other people, the environment, school work? If yes, please explain.

EXECUTE

1. Compared to children the same age, tell me about your child's ability to know when and/or in what order to use learned routines for things.
2. Does this ability vary depending on whether your child is dealing with sensations, feelings, thoughts, or actions? If yes, please explain.
3. Does this capacity vary depending on whether the sensations, feelings, thoughts, or actions involve just your child, other people, the environment, school work? If yes, please explain.

MONITOR

1. Compared to children the same age, tell me about your child's ability to know when to closely monitor or keep track of things.
2. Does this ability vary depending on whether your child is dealing with sensations, feelings, thoughts, or actions? If yes, please explain.
3. Does this capacity vary depending on whether the sensations, feelings, thoughts, or actions involve just your child, other people, the environment, school work? If yes, please explain.

CORRECT

1. Compared to children the same age, tell me about your child's ability to know when to cue and use routines for correcting errors.
2. Does this ability vary depending on whether your child is dealing with sensations, feelings, thoughts, or actions?If yes, please explain.
3. Does this capacity vary depending on whether the sensations, feelings, thoughts, or actions involve just your child, other people, the environment, school work? If yes, please explain.

SELF-REALIZATION: SELF-AWARENESS

1. Does your child realize that he/she is an independent person with his/her own perceptions, thoughts, feelings, and actions?
2. Does your child have an awareness of his/her own capacity to control his/her own perceptions, emotions, thoughts, and actions? If yes, please explain.
3. Is your child able to think about and understand what other children might be thinking or understanding? If yes, please explain.
4. Does your child understand that how they experience a situation in terms of perceptions, emotions, thoughts, or actions can be very different from how another child experiences the same situation? If yes, please explain.

SELF-REALIZATION: SELF-ANALYSIS

1. Does your child make statements that reflect an awareness of his/her own strengths and weaknesses?
2. Are these statements realistic appraisals of what you see to be your child's strengths and weaknesses?
3. Does your child realize that others hold opinions about them?
4. Does your child have a self-developed, realistic idea about what those opinions might be?
5. Does your child realize what kind of effects his/her actions might have on others? If yes, please explain.
6. Does your child spend much time reflecting on situations in which they've been involved and ways to improve the outcomes of such situations? If yes, please explain.

SELF-DETERMINATION: GOAL GENERATION

1. Does your child ever set long-term (one week away or longer) goals? If yes:
   How often?
   What kind of goal(s)
   Was your child successful (fully or partially) in achieving the goal(s)?
   
2. Does your child have any long-term goals right now? If yes, what is/are the goal(s)?

SELF-DETERMINATION: LONG-TERM FORESIGHT AND PLANNING

1. Does your child understand that many actions have long-term consequences?
2. Is your child effective at predicting or anticipating the long-term consequences of specific behaviors?
3. Is your child able to link future events or circumstances with present-day behavior?
4. Does it occur to your child to consider the benefits of delaying reward to a later time?
5. Has your child ever engaged in planning for a long-term personal project or school assignment?
   If yes:
   What was the project/assignment?
   
   Was your child's planning effective for completing the project/assignment?
   
   
   
6. Is your child working on any long-term projects/assignments right now? If yes, what is the project/assignment?

SELF-DETERMINATION: INDEPENDENT FUNCTIONING

1. Has your child demonstrated a desire to do things on his/her own? If yes, please explain.
2. Does your child order his/her own food from a menu when you go out to eat?
3. Does your child purchase his/her own clothing or ask for specific clothes to be purchased?
4. Does your child make his/her own choices of what to wear to school everyday?
5. Does your child make his/her own decisions about school clubs or activities in which to participate?

SELF-GENERATION

1. Has your child asked you many questions about the deeper meaning of life or wanted to discuss these kinds of questions? (For example, why people exist or where people came from? What happens to people after they die? Does God exist? How were the things that exist in the world created? What is the meaning or purpose of life?) If yes, please explain.
2. If your child does discuss these topics, is the emotional tone positive, negative, or neutral?
3. Has your child ever expressed the opinion that life has no meaning or that nothing in life really matters? If yes, please explain.