BACKGROUND INFORMATION

Please complete to the best of your knowledge and submit before your child’s next appointment.

Young Person's Information

Child's First name *

Surname *

Person filling this form *

Languages spoken at home other than English

Does your child live with both parents? If not, what is the current living arrangement? Please describe briefly.

Who else does your child live with? (Don't include parents) (Siblings, relatives, family friends etc.)

Name

Age

Gender

Relationship to child

From the relative’s names above, does anyone have a medical or developmental concern? Please describe

Your Child's Support Network

Please list the names of any other past or present professional support

Other Psychologist

Length of Treatment

Reason to Visit

Name of Practice

Speech Therapist

Length of Treatment

Reason to Visit

Name of Practice

Occupational Therapist

Length of Treatment

Reason to Visit

Name of Practice

Neurologist

Length of Treatment

Reason to Visit

Name of Practice

Physiotherapist

Length of Treatment

Reason to Visit

Name of Practice

Other?

Length of Treatment

Reason to Visit

Name of Practice

Educational Support

Name of School

Year Level

Teacher

Key School Support Person

Is your child in a special class or receiving any support services (specify)?

SECTION A: FAMILY OF ORIGIN (PSYCHOLOGY)

Please describe any family history of developmental delays, Autism Spectrum Disorders (including Asperger’s Syndrome), or mental health issues on either side of the family. Please include any history of diagnosed or undiagnosed anxiety, depression, substance abuse/dependence, gambling, smoking, domestic violence

Maternal Side

Paternal Side

Current Parental Relationship

PartneredMarriedDivorcedSeparated

For how long?

Since your child’s conception, have there been any significant periods of parental separation or relationship conflict? If yes, please describe briefly.

Was there any history of miscarriages, stillbirths, terminations, or abortions before or after the birth of your child? If yes, please describe briefly.

SECTION B: CHILD DEVELOPMENTAL HISTORY

What is your child’s birth order?

1st 2nd 3rd 4th

Other

Was the pregnancy planned?

YesNo

Were there any significant complications during pregnancy? If yes, please describe (infections/illnesses/injuries to mother or baby)

Was alcohol or any other substances/medication used during pregnancy? If yes, please describe:

Length of Pregnancy

Length of Labour

Labour was

normalshortprolongedinduced

Delivery was

normalbreachcaesareanforceps used

Was your child intubated? If yes, how long?

Were there any other complications at birth? (jaundice, seizures, transfusions, maternal health)

Describe any concerns at discharge:

Child was

BreastfedBottle-fed

Please describe your child’s temperament in infancy:

Medical History

How is your child's general health?

Has your child had any history of the following? If yes please describe and give dates.

• Childhood or major illnesses?

• Surgery?

• Serious injury?

• Seizures?

• Frequent upper respiratory infections?

• Frequent ear infections?

• Neurological treatment?

• Casts or braces?

• Gastrointestinal problems (such as diarrhea, stomach ache, vomiting, constipation)?

• Allergies?

• Dietary restrictions?

Does your child currently take any medications? (If yes, please list the names of the medications and state the condition for which it is taken):

Motor Development

At what age did your child do the following?

Crawl

Walk

Was the crawling phase prolonged, brief or entirely eliminated?

At what age was your baby introduced to pureed foods?

At what age was your baby introduced to solid foods?

Any fine motor difficulties? (i.e., handwriting, unbuttoning, picking up objects)

Any gross motor difficulties? (coordination, climbing, balance, bumps into things, clumsy):

SECTION C: SPEECH AND LANGUAGE SCREENING

When did your child start saying single words?

Sentences?

Any second languages?

Does your child have any speech or language issues/delays? Please describe any concerns:

Does your child have any stutter or dysfluencies in speech? If yes, is your child aware, concerned, or frustrated by their difficulties in speech?

Do you have any concerns in relation to your child’s social skills? i.e., joining in, taking turns, interacting with peers. Please describe:

Has there been any history of feeding difficulties? Please describe.

Any other speech or language concerns?

SECTION D: CHILD SOCIAL/EMOTIONAL DEVELOPMENT

Child Care: Did your child attend child care/occasional care/family day care?

If yes:

At what age?

How many days per week?

Until what age?

Were there any separation anxiety issues?

Kinder: Please describe any social issues, transitional issues, or significant separation anxiety during Kinder.

Primary School:

Please describe any social/friendship issues, bullying, transitional issues, significant separation anxiety or teacher conflict issues during Primary School:

Please describe your child’s academic strengths and weakness at school:

Has your child had any formal cognitive/psychological/language assessments? If so, please describe and give the year of testing

Social Development and Play Skills

How would you describe your child’s personality in a couple of words?

What do you see as your child’s social strengths?

What do you see as your child’s social challenges?

Behavioural/Emotional Components

Briefly describe your child’s behaviour at school:

Briefly describe your child’s behaviour at home:

Briefly describe your child’s mood over the past month:

What does your child do when angry or frustrated?

How does your child calm himself/herself when upset:

Briefly describe your child’s functioning over the past month:

Sleeping: (i.e., difficulty falling asleep? Settles well? Sleeps through the night? Light or heavy?)

Appetite or feeding:

Play: (i.e., favourite activities, toys, games)

Does your child have a preference to play with others or play alone?

Does your child have any difficulties with attention/concentration/remaining on task? (please describe)

SECTION E: SENSORY SCREENING

Does your child have any sensory issues in the following areas? (Hypersensitive/Hyposensitive)

Visual:

Auditory:

Taste/Oral:

Tactile (Touch):

Smell:

Movement/Body awareness:

Coordination:

OTHER:

Is there any other information you think would be useful for us to know in developing a treatment plan for your child? Please describe

Thank you for taking the time to complete this form.