Preference Assessment Interview - Richmond Public Schools
[Pages:7]Preference Assessment Interview
Student: Date:
Parent: Teacher
Please complete the questions to the best of your ability.
Section 1:
Food Items
Please think about certain foods that your child prefers such as peanut butter, Twizzlers,
and ice cream. Below please check whether each food is highly preferred, somewhat
preferred, not preferred at all. There is space at the end to add additional items not listed.
Item:
Highly Somewhat Not Preferred
Notes:
Preferred Preferred
at All
(types, brands, etc..)
Candy
Gum
Crackers
Cookies
brownies
Chips
Apples
Grapes
Pears
Oranges
Strawberries
Melons
Pineapple
Vegetables
Chicken
Hamburgers
Hotdogs
pizza
French fries
Fruit snacks
Yogurt
Cheese
Ice cream
Pretzels
Section 2:
Drink Items
Please think about certain drinks that your child prefers such as water, juice, soda. Below
please check whether each food is highly preferred, somewhat preferred, not preferred at
all. There is space at the end to add additional items not listed.
Item:
Highly Somewhat Not Preferred
Notes:
Preferred Preferred
at All
(types, brands, allergies, etc..)
Soda
milk
juice
tea
coffee
Kool-aid
Chocolate milk
Hot chocolate
Section 3:
In this section, try to note and think about items your child enjoys looking at that includes
specific videos, tv shows, computer games, books, etc... This may even include things
that mean seem "strange" like watching his/her hand move through the air or other toy
items that he/she may watch closely
There is space at the end to add additional items not listed.
Item:
Highly Preferred
Somewhat Preferred
Not Preferred at All
Notes:
(types, brands, allergies, etc..)
Mirrors
Bright lights
Shiny objects
Spinning
objects
TV shows
(list in list box)
Movies
(list in last box
Long objects
(like pencils, flags, sticks)
Computer Games
(list in last box)
Section 4:
In this section, try to note and think about items your child enjoys looking at that includes
specific videos, tv shows, computer games, books, etc... This may even include things
that mean seem "strange" like watching his/her hand move through the air or other toy
items that he/she may watch closely
There is space at the end to add additional items not listed.
Item:
Highly Preferred
Somewhat Preferred
Not Preferred at All
Notes:
(types, brands, allergies, etc..)
Mirrors
Bright lights
Shiny objects
Spinning
objects
TV shows
(list in list box)
Movies
(list in last box
Long objects
(like pencils, flags, sticks)
Computer
Games
(list in last box)
Section 5:
In this section, try to note and think about items your child enjoys listening to...
There is space at the end to add additional items not listed.
Item: Music
Highly Preferred
Somewhat Preferred
Not Preferred at All
Notes:
(types, brands, allergies, etc..)
(list types)
Car sounds
Whistles
Alarm/Siren
Sounds
Clicking noises
Clapping
echoes
Funny voices
Whispering
Water sounds
(splashing,
dripping,
pouring)
Section 6:
In this section, try to note and think about items your child enjoys smelling.
There is space at the end to add additional items not listed.
Item:
Highly Preferred
Somewhat Preferred
Not Preferred at All
Notes:
(types, brands, allergies, etc..)
Foods
Soaps
Perfumes
Flowers
Grass
Candles
Section 7:
In this section, try to note and think about gross motor activities that your child enjoys to
participate in.
There is space at the end to add additional items not listed.
Item:
Highly Preferred
Somewhat Preferred
Not Preferred at All
Notes:
(types, brands, allergies, etc..)
running
Jumping
Spinning
Rolling
Gymnastics
Being tickled
swimming
Wrestling
Swinging
Kicking balls
Throwing balls
sliding
Section 8:
In this section, try to note and think about other activities that your child enjoys
participating in.
There is space at the end to add additional items not listed.
Item:
Highly Preferred
Somewhat Preferred
Not Preferred at All
Notes:
(types, brands, allergies, etc..)
Reading books
Puzzles
Playing games
Painting
drawing
Craft activities
Cooking
Taking walks
Listening to music
Kicking balls Throwing balls
sliding Playing on computer
Sports Karate Playing with water Play-dough Sensory type activities
(brushing skin, weighted blanket,
bean bag)
Hugs Rubbing head Playing cars
Balloons Bubbles Flashlights Blocks Legos barbies
Section 9: Finally, please list any other things your child really enjoys or really dislikes that wasn't mentioned above.
Thank again for your input and support!!
................
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