Parent Referral and Background Questionnaire
Please complete what is relevant
Child's name
Birthdate:
Age:
Male
Female:
School:
Grade:
Reason for referral
I give permission for Growth Mindset Centre to carry out assessments and/or counselling as required:
Yes
No
In providing the best support for your child, do you give permission for Growth Mindset Centre to exchange information, if needed, with other professionals?
Yes
No
Parent/Guardian signature
Draw signature
|
Type signature
Clear
Date
1. Family Data (Please complete what is relevant)
Child's home address:
Mother's/Caregivers Name:
Phone Number:
Email:
Father's/Caregivers Name:
Phone Number:
Email:
Is your child Aboriginal or Torres Strait Islander?
Yes
No
Person filling out this form:
Mother
Father
Stepmother
Stepfather
Other
Mother/caregivers level of education:
Secondary School
TAFE
University
Occupation:
Father/caregivers level of education:
Secondary School
TAFE
University
Occupation:
Marital status of Parents:
If separated/divorced, how old was the child?
Step-parents Name:
Level of Education:
Secondary School
TAFE
University
Occupation:
List all people living in household and relationship to child:
If any siblings living outside the home, list their names and ages:
Primary language spoken in the home:
2. Early Development
Did your child meet age expected milestones? (e.g. talking, walking, toileting)
Yes
No
If no, please describe any concerns you had for your child's early development.
Has your child ever been seriously ill or had an accident?
Yes
No
If yes, please explain
3. Education (Please complete what is relevant)
What pre-school did your child attend?
How many days a week?
Did the pre-school teacher have any concerns about your child?
Yes
No
If yes, please explain
Please indicate any educational problems that your child currently exhibits:
Difficulties with reading
Difficulties with spelling
Difficulties with writing
Difficulties with Mathematics
Has behavioural problems
Has friendship problems
Does not like school
Other
If other, please explain
Is your child in a special education class?
Yes
No
If yes, what type?
Has your child been held back in a grade?
Yes
No
If yes, please explain
4. Presenting Problem
Briefly describe your child's current difficulties:
How long has this been of concern to you?
When was the problem first noticed?
What seems to help the problem?
What seems to make the problem worse?
Has your child received assessment or treatment for the current problem or similar problems?
Yes
No
If yes, when and by whom?
Has your child received any diagnosis?
Yes
No
If yes, please explain:
Is your child currently on any medication?
Yes
No
If yes, please explain:
Please indicate any behaviour or problems your child currently exhibits:
Difficulty with speech
Difficulty with hearing
Difficulty with language
Difficulty with vision
Difficulty with coordination
Rocks back and forth
Bangs head
Does not get along with brothers and sisters
Eats poorly
Is stubborn
Has poor bowel control (soils self)
Engages in behaviour that could be dangerous to self or others
Has special fears, habits or mannerisms
Is slow to learn
Wets bed
Has frequent tantrums
Has frequent nightmares
Has trouble sleeping
Prefers to be along
Holds breath
Is aggressive
Is shy or timid
Is more interested in objects than in people
Is much too active
Is clumsy
Has blank spells
Is impulsive
Shows daredevil behaviour
Gives up easily
Bites nails
Sucks thumb
Other
Is there anything else you would like the psychologist to know about your child?
Please wait, files are uploading..
Submit
