School Avoidance Assessment Questionnaire Form
Use this questionnaire to describe school avoidance patterns, common triggers, and current impact so the situation can be better understood.
Assessment Overview
Relationship to the student
*
Parent/guardian
Teacher
Counselor
Self-report
Other
Student age or grade level
*
Main reason for completing this questionnaire
School Avoidance Pattern Assessment
How often does school avoidance occur?
*
Never
1
2
3
4
Very often
5
1 is Never, 5 is Very often
When does school avoidance happen most often?
*
Morning before school
During the school day
On specific days
After weekends or holidays
Other
Common triggers or situations
*
Rows
Not a trigger
Mild trigger
Moderate trigger
Strong trigger
Separation from caregiver
1
2
3
4
Peer interaction
5
6
7
8
Classroom participation
9
10
11
12
Transportation to school
13
14
15
16
Tests or evaluations
17
18
19
20
Transitions between activities
21
22
23
24
Bullying concerns
25
26
27
28
Sensory or environmental discomfort
29
30
31
32
What is the level of impact on attendance or participation?
*
1
2
3
4
5
Impact and Support Needs
Typical signs or behaviors when school avoidance occurs
*
Current support strategies in use and how helpful they are
*
None
Informal support from family or friends
School accommodations
Counseling support
Gradual routine changes
Other
Additional comments or concerns
Submit
Should be Empty: