Full Name:

Name: Date:
Age: First Language:
Educational Background:
Last school attended:
Last grade attended:
Last grade completed:
Date last attended:

This questionnaire gives you a chance think about and communicate to the teacher what you’d like to learn and how you learn best. The EEE program is designed to help you learn and reach your goals. To make it work, you must communicate goals, strengths and needs as specifically as you can.

There are no right or wrong answers. The more information you can give about any answer, the better. Feel free to use extra paper if you need more room to write.

SELF-RATING
My reading skills are: [ ]Excellent [ ]Good [ ]Fair [ ]Need Work
Please explain:
Do you understand most of what you read?

When do you read?

What do you like to read?

If you don’t understand a word when you read, do you try to guess the word’s meaning by looking at the words around it and fitting it into the story? Can you think of a time when you did this?



I also enjoy:
[ ]cartooning [ ] painting [ ]drawing [ ] singing [ ]Other

LIFE SKILLS
Describe a situation where you were able to help yourself or someone else accomplish something (some examples may include solving a problem between people, doing a budget, doing something good for your health, etc.):



Have you ever been unable to do something you really wanted to do because you didn’t have the necessary skills or information? Please describe

A personal characteristic I would like to work on is __________
because

Name at least two things you’ve seen or heard about and would like to understand better
1.
2.

Would you rather read a good story or a news magazine? Why?

Would you rather listen to an older relative talk about your family history or listen to the news? Why?

Would you rather discuss personal and social values and how they fit into your life or how the body works? Why?

Name at least two other things you enjoy reading about or discussing (some examples might be hobbies, places you’ve lived, sports, current events or news you’re concerned about, health, movies, music, etc.):

Do you learn better working with others or alone? Please explain.

1.
2.
3.
4.
5.

Other things I would like to learn (please describe any experience with the following):

managing money effectively
understanding pricing, discounts, etc.
registering to vote
getting a library card
learning to use the library
getting involved in community activities
learning about careers such as
protecting my health effectively
managing time effectively

Please add at least one other thing you would like to learn

WEEKLY PLAN

Name:
Date:
My plan for this week is (include page numbers, specific tests, writing, as well as understanding concepts and ideas, etc.):
1.

2.

3.

4.

5.

Please write down the date each day you are in class and comment on what you accomplished and how class went that day. Feel free to change or add to your list above as the week goes on.

USE THE BACK OF THIS PAGE IF YOU RUN OUT OF ROOM

Day

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