BANYAN TREE YOGA THERAPY
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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?
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2. What degree and type of hearing loss does your child(ren) have?
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3. Does your child(ren) have any other conditions? If yes, please specify.
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4a. Does your child(ren) contend with any anxiety, depression, or other psycho-emotional concerns?
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Yes
No
If yes, please list.
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4b. If you answered Yes in question 4, do you think these concerns are related to hearing loss?
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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.
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6. Are you/your family culturally Deaf?
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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?
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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.
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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?
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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.
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13. Have you dealt with any specific behaviours you consider related to your child(ren)'s hearing loss?
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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?
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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
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Home
Yoga Therapy
Yoga Therapy
>
FAQs
Rates
Adaptable Yoga Privates
More
Contact
Advocacy
Code of Ethics
Terms & Conditions