PARENT QUESTIONNAIRE

This questionnaire is to gather information about your child before assessment. Your answers will help me to get to know your child better and to understand your concerns about your child. Please let me know if there is any information that you would prefer not to be included in your child’s report, or shared with schools or other professionals.

Name of your child *

First

Last

Date of birth *

Parent/s name *

First

Last

School *

Email *

Current year at school *

Teacher *

What is your main reason for seeking help? *

What are your main areas of concern for your child? *

Is the first time that you have sought help for these sorts of concerns? *

Is your child receiving any professional help such as from a Speech Pathologist or OT, or any help at school/preschool? *

Has your child been diagnosed with any particular condition? *

Are there any family factors you would like to mention? *

DEVELOPMENTAL PROGRESS

Was your child delayed in any developmental area? e.g. crawling, walking, toileting, feeding, language? *

How are your child’s self help and organisation skills developing? *

PROGRESSS AT SCHOOL

What are your child’s academic strengths and challenges? *

What problems does your child face at preschool/school? *

FRIENDSHIP AND EMOTIONAL SKILLS

How are your child’s friendship skills developing? *

How is your child developing in self confidence and resilience? *

Does your child become anxious or excessively worried about things? *

BEHAVIOUR

What concerns, if any, do you have about your child’s behaviour at home or school/preschool? *

How cooperative is your child in following instructions? *

Do you need to monitor and limit your child’s playing or participating in one particular interest? *

Is your child more or less active than other children the same age? *

How easy going is your child? How does your child respond to any major changes? *

MOTOR SKILLS AND SENSORY ISSUES

How would you describe your child’s physical skills (running, climbing, ball skills, sports skills)? *

Does your child have any fine motor difficulties? (e.g. holding a pencil, writing, eating, cutting)? *

Does your child have any sensory issues? *

OTHER DETAILS

Is there any other information that you would like to share with me? *

Message

Thank you for completing this questionnaire.

Please bring this form completed to your first appointment, or return it to our office,

fax on 8357 0045 or email reception@connectpsych.com.au

PARENT QUESTIONNAIRE

PARENT QUESTIONNAIRE

PARENT QUESTIONNAIRE

Hyde Park

Collinswood

Aldgate

Hyde Park

Collinswood

Aldgate