School child background form

School-age Child Background Questionnaire (1)

  • Add a new row
  • Goals of assessment &/or therapy

  • Developmental History

  • List any issues with pregnancy &/or labour (e.g. hypertension, resuscitation, prematurity etc)
  • Issues learning to stand or walk? Current concerns with fine or gross motor skills? Please note if your child has seen an occupational therapist. Please bring any reports to your initial consultation.
  • Please note if your child was slow to talk, or current has any language issues (e.g.. with comprehension or language expression). Please note if your child has seen a speech therapist. Please bring any reports with you to your initial consultation.
  • Does your child have either a history of sleep issues, or any current sleep problems? Please note if your child has issues falling asleep, whether they wake in the night, and whether they are difficult to rouse in the morning.
  • Please note if you have any concerns with your child's social development eg. issues making friends, issues keeping friends, poor eye contact, issues with empathy etc.
  • Please note if your child has a history of, or current issues with their behaviour. Please specify what these concerns are e.g.. tantrums, anger, aggression, oppositional behaviour, inflexibility, etc.
  • Please note any history or current issues with any emotional problems such as depression, anxiety, obsessive behaviour, school refusal etc. Please indicate if your child has seen a mental health professional for these issues, with whom, and for how long.
  • Medical Background

  • Please note any relevant medical issues such as genetic disorders, head injury, epilepsy, ear infections, headache, migraines, enuresis, encopresis, hydrocephalus etc.
  • Please list if you child is on any medications and include dosage.
  • Please list any relevant hospitalisation, injuries or significant illnesses.
  • Family History

  • Please note any family history of any cognitive, learning, psychological, medical, genetic or behavioural disorders which may be relevant to the current assessment.
  • Educational Background

  • Please note any concerns with your child's learning. Note which areas you have concerns with, whether you feel they are underperforming. Please bring schools reports and NAPLAN if available to your initial consultation.
  • Assessment Cancellation Policy

    Please tick the boxes below to indicate that you agree to all the terms and conditions.
  • Therapy Cancellation Policy

    Please tick the boxes below to indicate that you agree to all the terms and conditions.