EnrichMyCare - Parent/Carer Questionnaire
Please complete this questionnaire to help us understand your child's needs. Your responses will support research and service development.
Internal ID
Section 1: Consent and About You
Please read the following and provide your consent to participate.
Please verify that you are human
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Name
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First Name
Last Name
What is your relationship to the child?
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Please Select
Parent
Foster Carer
Step-parent
Guardian
Other
Please enter your email address (only if you wish to receive a £15 Amazon voucher):
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Confirmation Email
Enter and then confirm your email.
Section 2: About Your Child
Tell us about your child and their background
Age of your child:
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Who does your child live with? (e.g., Parents, siblings, grandparents etc).
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0/200
Has your child experienced any difficult life events (e.g., family separation, trauma, parental illness)?
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0/200
Section 3: Developmental Concerns
Share your observations and concerns about your child's development.
What are your main concerns about your child’s development?
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0/200
Do you think your child may have any of the following conditions?
Autism
ADHD
Learning Difficulty
Other
Describe any early delays in motor, speech, or learning development.
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0/200
How does your child interact with others? Include communication style, friendships, eye contact, gestures, play.
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0/200
Does your child show repetitive behaviours, rigid routines, or intense interests?
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0/200
Does your child have any sensory difficulties (e.g. sound sensitivity, texture avoidance)?
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0/200
Any other behaviour concerns (e.g. sleep, aggression, anxiety)?
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0/200
What are 3 of your child’s strengths and 3 of your concerns?
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0/200
Section 4: Daily Functioning
Tell us about your child's daily skills and support needs.
Is your child independent with dressing, toileting, and meals?
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Yes
No
If Yes, please add details:
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0/150
Do they have coordination or organisation difficulties (e.g. cutlery use, riding a bike, remembering tasks)?
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Yes
No
If Yes, please add details:
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0/150
What support has your child received so far (e.g. therapy, SENCO, classroom help)?
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0/200
What strategies or routines have helped or not helped your child?
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0/200
Section 5: Family & Medical History
Please provide information about your family's and child's medical history.
Is there a family history of any of the following?
Autism
ADHD
Learning Difficulties
Mental Health
Genetic Conditions
Was the pregnancy or birth complicated in any way?
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Yes
No
If Yes, please add details:
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0/150
Has your child had any hospitalisations, regular medications, or ongoing conditions?
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Yes
No
If Yes, please add details:
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0/150
Section 6: Behaviour Checklist
Please rate how often your child displays the following behaviours.
Behaviour Checklist
Rows
Never
Rarely
Occasionally
Often
Always
Easily distracted
Difficulty sustaining attention
Does not seem to listen
Fails to finish tasks
Difficulty organizing tasks
Avoids tasks requiring mental effort
Loses things necessary for tasks
Forgetful in daily activities
Difficulty following instructions
Fidgets or squirms
Leaves seat when expected to remain seated
Runs or climbs excessively
Difficulty playing quietly
Acts as if driven by a motor
Talks excessively
Blurts out answers
Difficulty waiting turn
Interrupts or intrudes on others
Tantrums or emotional outbursts
Difficulty managing frustration
Irritability
Aggressive behaviours
Withdrawn or isolated
Rapid mood changes
Difficulty calming down
Worries excessively
Sensitive to criticism
Section 7: School and Final Questions
Final questions about your child's school experience and any additional information.
Is your child working at age-related expectations?
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Yes
No
Is your child on the SEN register?
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Yes
No
Has your child experienced exclusions because of their current profile?
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Yes
No
Are they struggling to reach potential because of current profile?
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Yes
No
Please give details of the above and anything else you feel relevant for referral:
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0/150
Would you be happy for EnrichMyCare to contact you for more information about your response?
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Yes
No
Type a question
Rows
Not Satisfied
Somewhat Satisfied
Satisfied
Any thoughts?
Service Quality
Cleanliness
Responsiveness
Friendliness
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