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PERSONAL INFORMATION

Child’s Full Name:

Preferred Name

Address:

Date of Birth:

Indigenous status:

School:

School Year Level:

Class Teacher/s:

Email:

PARENT/CARER INFORMATION

Parent/Carer 1 name:

Relationship to child:

Address (if different to above):

Indigenous status:

Phone:

Mobile:

Email:

Are shared care arrangements in place? (Please tick)

If Yes, please provide details:

Yes

No

REFERRAL INFORMATION

Please indicate any specific concerns you have about your child’s participation at school, home or in the community. Identify any particular tasks he/she has more difficulty with than his/her same aged peers.

REFERRAL INFORMATION

Please indicate any specific concerns you have about your child’s participation at school, home or in the community. Identify any particular tasks he/she has more difficulty with than his/her same aged peers.

What impact do these concerns have on your child’s life?

Is there anyone else in your family that has/had similar issues? Yes No

HEALTH

Please provide details of GP if you would like copies of reports to go to him/her

GP Name:

GP Contact details:

Does your child have any significant health problems? Yes No Please comment:

Does your child have any allergies? Yes No Please comment:

Has your child had an assessment of hearing? Yes No If Yes, Please provide details:

Has your child had an assessment of eyesight? Yes No If Yes, Please provide details:

Is your child on any medication? Yes No Please specify with dosage:

Has your child had any contact in the past with or is currently seeing any of the following?

Service	Yes/No	Who	When	Contact Details
Paediatrician
Occupational Therapist
Physiotherapist
Psychologist
Speech Pathologist
Optometrist
Hearing specialist
Other

Does your child:	Yes/ No	Comments
Play with others?
Withdraw?
Prefer a group?
Have friends at home/school?
Have trouble making friends?

Are any of these behaviours causing concern? (Please tick)
Lack of eye contact	Yes No	Dislike of changes to routine	Yes No
Nervous habits	Yes No	Poor sleep habits	Yes No
Aggression	Yes No	Distractibility	Yes No
Excessive tantrums	Yes No	Becomes frustrated	Yes No
Obsession about a toy/object/topic	Yes No	Other (describe)	Yes No

	Early	Usual Time	Late	Not sure	Usual Age
Smile					6 weeks
Roll					4-6 months
Sit					6-7 months
Crawl					7-9 months
Walk					12-15 months
Talk (words)					12-18 months
Talk (sentences)					18-24 months

Parent questionnaire:

PERSONAL INFORMATION

PARENT/CARER INFORMATION

REFERRAL INFORMATION

REFERRAL INFORMATION

HEALTH

SOCIAL EMOTIONAL

EARLY DEVELOPMENT

	Please tick	Please comment
Feeding (breast/bottle)	Yes No
Eating/drinking	Yes No
Sleeping	Yes No
Toilet training	Yes No
Dressing	Yes No