HearingLoss_Parent_Survey

Banyan Tree Yoga Therapy

Home
Adults
Children
Teachers
Contact
About
Blog

Therapeutic Benefit of Yoga-Based Mindfulness for Children with Hearing Loss

This Survey is for Parents/Guardians of Children with Hearing Loss

If you are a professional serving children with hearing loss, please complete that survey here.
Both a parent and a professional? Please consider completing both surveys. Thank You!
Find out more about this project here.

Background Information on Your Child & Family Life

* Indicates required field

1. What age is your child(ren) with hearing loss? *

2. What degree and type of hearing loss does your child(ren) have? *

3. Does your child(ren) have any other conditions? If yes, please specify. *

4a. Does your child(ren) contend with any anxiety, depression, or other psycho-emotional concerns? *

Yes No

If yes, please list. *

4b. If you answered Yes in question 4, do you think these concerns are related to hearing loss? *

Yes, confirmed by our medical practitioners Yes, but not confirmed by our medical practitioners No I don't know Not applicable

5. Do you know why your child(ren) is deaf? If yes, please specify. *

6. Are you/your family culturally Deaf? *

Yes No I don't know

7. What technology does your child(ren) use? *

None Cochlear Implants Hearing Aids BAHA Bi-modal (please specify) Other (please specify) More than one child with different tech? Please specify

Please provide any details on technology below: *

8. Primary language(s) of communication? *

Spoken Signed Bilingual

Please provide any details on your primary language(s) of communication. *

Your Child's Unique Details

9. What factors contribute to your child(ren)'s ability to hear and focus in SMALL groups? Check all that apply. *

Room set up Class format Child's energy level General energy level - class, other children, etc. Noise Other children's behaviours Other - please specify

Please check all that apply.

Please provide any details: *

10. What factors contribute to your child(ren)'s ability to hear and focus in LARGE groups? Check all that apply. *

Room set up Class format Child's energy level General energy level - class, other children, etc. Noise Other children's behaviours Other - please specify

Please provide any details: *

11a. Did your child(ren) have any challenges transitioning to mainstream school? *

Yes No Not Applicable

11b. What kind of school does your child attend? *

Public Private Specialty (pls describe below)

Please describe any details about type of school. *

12. What has been your experience in general with your child(ren) in social/group situations? What factors have contributed to your child(ren)'s success? And what, if anything has been a detriment to success? (ex: daycare, preschool, kindergarten, school, social/extracurriclar activities, etc. *

13. Have you dealt with any specific behaviours you consider related to your child(ren)'s hearing loss? *

Yes Not related to hearing loss I don't know

14. Is there anything else you believe your child(ren) contend with due to hearing loss? *

Yes No I don't know

If you answered Yes above, please describe. *

Additional Information

15. Please use this space if you have anything else to add based on your experience. Or, if there is anything you think I've missed that you recommend I include in this survey. *

Your country, region (province/state), and city of residence *

Your Personal Information - OPTIONAL

Please complete below ONLY if you wish to be kept informed of this project and its resulting programs.

Name *

First

Last

Email *

I agree to receiving marketing and promotional materials

Submit

Banyan Tree Yoga Therapy | Yoga Therapy |Adaptable Yoga | Toronto ON
stephanie@banyantreeyt.com | 416-998-4791