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* 1. Your Name (the parent requesting this service) 

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* 2. What do you go by?

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* 3. How many kids do you anticipate having at home during this semester? 

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* 4. What are the ages of your children that you will be teaching? 

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* 5. If there is a child(ren) with a specific diagnosis tell me about your world + a bit about your daily life.

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* 6. Tell me your current plans for school this year. (Homeschool, virtual, etc). 

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* 7. What is your personal schedule and how will it intersect with your child's learning time? 

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* 8. Let's chat about your child(ren) with special needs. Give me a background on development, skillsets, communication methods, preferences, etc. (Example: Johnny is 10 and is currently working to learn his colors. He communicates by looking one way for YES and one way for NO. He loves cartoon movies and asks to play with playdough everyday).

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* 9. What are 5 things your child really enjoys? If there are interests that are shared by multiple siblings or the entire family include those as well. (Example: Amanda loves balls. She also loves the movie Mary Poppins. Her siblings love that movie as well. As a family we like to go camping together). 

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* 10. What does your child(ren)'s independence look like? Are there activities they enjoy doing alone?

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* 11. List equipment and/or services you have at the house that can assist in home learning. (Example: AAC device, HULU / Netflix, a tablet, a stander that can allow my child to stand while working, etc).

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* 12. If you are wanting to include other children in this session, tell me about their interests and skill levels here.

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* 13. If you have a schedule or routine set up, tell me about it here. If you want help creating one let me know here as well. 

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* 14. What are your biggest concerns for this time of home-learning?

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* 15. What are your biggest hopes for this time of home-learning?

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* 16. What questions would you like me to brainstorm on the most in this session? 

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* 17. Is there anything else you want Dr. McConnell to know? 

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* 18. I understand that upon her reviewing this survey, Dr. Mary Susan McConnell will decide if she believes she can be of assistance. If so, I will be notified and invoiced for $67. Once the invoice is paid (via PayPal or Venmo) she will begin working on my case and will email me a personalized audio file of her speaking her ideas within 48 business hours.

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* 19. I understand I am paying for the time Dr. McConnell spends on my case and not on the results of her ideas. 

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* 20. We hope to work with you! Please complete the contact info below and then hit "submit" when you are done. Thank you so much! 

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