Four Diamonds Needs Assessment Form

FOUR DIAMONDS

NEEDS ASSESSMENT FORM

The mission of FOUR DIAMONDS is the pursuit of the following principles:

* Commitment: FOUR DIAMONDS wants to inspire social friendships, strong interpersonal skills, and instil a sense of hope in the future.

* Responsibility: The focus of FOUR DIAMONDS is to empower children in establishing goals and following through on commitments.

* Possibility: FOUR DIAMONDS wants to expand the perspective of children to make them aware of all life's possibilities.

* Support: An individual is dramatically influenced by their support system. FOUR DIAMONDS wants to surround these children in a caring, inclusive safe supporting environment.

We believe in these four principles (4 diamonds) that help to provide healthy growing relationships in the development of all our children's life.
THE PROCESS:

1. The purpose of this assessment is to determine what level of care your child requires and to make sure we can provide a safe, secure and fun environment so they can be included into a "mainstream programme." Four Diamonds is for neurodivergent children. The programme is NOT designed for children with high needs physical/intellectual disabilities.

2. Please answer all the questions - Everything with asterisks * must be completed

3. Please be as detailed as possible in your form as this can delay our assessment if we have to come back to you asking for further information.

4. Due to increased enquiries please allow up to 20 working days for your assessment to be completed by our team.

5. Contact will be made via email.

6. A visit maybe required by yourself and your child, an appointment will be sent to your via email

7. A client number will be allocated to your child upon assessment approval which will let you book your child into Four Diamonds Programmes. Without this number your booking will not go ahead.
Your preferred centre location:*

Stokes ValleyLower HuttNo preference
Please select the sessions you are interested in for this child*

After School Session (3.30pm - 5.00pm)Half day 8.30am to 3.30pm (school holidays)Full day 7.30am to 5.30pm (school holidays)
Childs Name*

First NameLast Name
Age of Child*
Sex of Child*

MaleFemale
School Attending*
Ethnicity Group your child most identifies with (this is collected for statistics purposes)

MaoriNZ EuropeanEuropeanPacific IslandAsianIndianMiddle EasternAfricanOther
Parent/Caregiver Name

First NameLast Name
Home Address*
Contact Phone Number*
Confirmation of your assessment form to be emailed to:*

Confirmation Email
DISABILITY - PLEASE TICK ALL THAT APPLY TO YOUR CHILD*

ADHD - attention deficit hyperactivity disorderFASD - Fetal alcohol spectrum disordersASD - Autism spectrum disorderODD - Oppositional Defiant DisorderGAD - Generalized Anxiety DisorderGDD - Global Development Delay/Learning DifficultiesOther
ADHD Level*

MildModerateSevereUndiagnosed
ADHD - Medication*

YES - My child is medicatedNO - My child is not medicated
ADHD - does a supervisor need to administer your child's medication?*

YESNOONLY IF REQUIRED
ADHD - Name of medication to be administered*
ADHD - Dosage of medication to be administered*
ADHD - Time of day medication to be administered*
FASD Level*

MildModerateSevereUndiagnosed
FASD - Please advise of any details/information here*
ASD Level*

High FunctioningLow FunctioningUndiagnosed
ASD - Please advise of any details/information here*
ODD Level*

MildModerateSevereUndiagnosed
ODD - Please advise of any details/information here*
GAD Level*

MildModerateSevereUndiagnosed
GAD - Please advise of any details/information here*
GDD Level*

MildModerateSevereUndiagnosed
GDD - Please advise of any details/information here*
OTHER Level*

MildModerateSevereUndiagnosed
OTHER - Please advise of any details/information here*
SENSORY - PLEASE SELECT ALL THAT APPLY TO YOUR CHILD*

Does not like loud/noisy placesDoes not like bright lightsDoes not like the darknessLicks objectsChews objectsN/AOther
SENSORY - PLEASE GIVE US EXAMPLES AND HOW YOU MANAGE THESE*
SOCIAL - PLEASE SELECT ALL THAT APPLY TO YOUR CHILD*

Does not do well in groups (10+)Does not do well in groups (20+)Does not do well in groups (30+)Does not do well in groups (40+)Has trouble making friends/keeping friendsHas trouble sharing/waiting for their turn/waitingN/AOther
SOCIAL - PLEASE GIVE US EXAMPLES AND HOW YOU MANAGE THESE*
PROCESSING - PLEASE SELECT ALL THAT APPLY TO YOUR CHILD*

Has trouble focusing on activities/tasksHas trouble listening/understanding instructionsHas trouble sharing/waiting for their turn/waitingN/AOther
PROCESSING - PLEASE GIVE US EXAMPLES AND HOW YOU MANAGE THESE*
BEHAVIOUR- PLEASE SELECT ALL THAT APPLY TO YOUR CHILD*

Has emotional outburstsLoses their temper easilyHits/lashes out at other children/adultsBites other children/adultsThrows objectsWill run out an open door/leave premises/wander away from the groupN/AOther
BEHAVIOUR - PLEASE GIVE US EXAMPLES AND HOW YOU MANAGE THESE*
OTHER - PLEASE SELECT ALL THAT APPLY TO YOUR CHILD*

My child is PARTIALLY verbalMy child is NON verbalMy child needs toileting assistance (wears nappies/is unable to go to the toilet by themselves)N/AOther
OTHER - PLEASE GIVE US EXAMPLES AND HOW YOU MANAGE THESE*
MY CHILD RESPONDS WELL TO:*

When they are spoken to face to faceTo be given notice prior to something happeningTo be given all instructions/rules at the beginning of they dayHanging out/playing with a staff memberHanging out/playing with another childPhysical playing (running around outside)Being left to play on their own and choose their own activityOther
ACTIVITIES FOUR DIAMONDS CURRENTLY PROVIDE - MY CHILD ENJOYS:*

Lego/Building blocksArts and CraftsPlaying with ToysBoard games/puzzlesReadingComputer games (these are limited to 1hour turns to allow all children to have turns during the day)Television/DVDSPretend playBaking/cookingOutside playSwimmingPublic Playground/ParkMovie theatreLaserforce/ArcadeSportsBeachTen Pin BowlingBouncy CastlesLaughalots PlaylandTrampoline ParkIceskatingPlaystationWii GamingConnecting with other children online (e.g roblox)Other
Does your child currently have a teacher aide at school*

YesCurrently waiting for a teachers aideNo
How long does your child have their teacher aide during a normal day*

A couple of hours per dayHalf a dayAll dayOther
Does your child require 1 to 1 supervision? (this means does your child need to be supervised the whole time - they cannot be left alone)*

Yes - They require their own personal supervisorSometimes - They will require their own personal supervisor dependant on the activity for the dayNo - They do not require their own personal supervisor and can be part of the standard ratio
Has your child attended another after school or school holiday provider before?*

YesNo
Please confirm which provider you have used and why you want to enrol into Four Diamonds instead of using them again*
DO YOU CURRENTLY RECEIVE FINANCIAL ASSISTANCE FOR YOUR CHILD*

ICAFSMinistry of HealthCDA (child disability allowance)Work and Income SubsidyI DO NOT receive financial assistance
Full Name*

First NameLast Name
How did you hear about us?*
Date Signed*
ANY OTHER COMMENTS OR NOTES YOU WOULD LIKE TO ADD, PLEASE FILL IN HERE
Documents you would like to attach (assessments, medical information, behaviour plan etc)

Upload Documents Here

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