Pre-Assessment Form

Background / History

Client Name:

D.O.B.

Parent / Guardian Contact Number

Address

School and Grade

How did you find out about our service?

Referral Reason:

What is being investigated? What are the symptoms observed at home and / or at school?

Family Context / Family History:

- Is there any family history of mental health challenges or learning difficulties? E.g. Dyslexia, Anxiety, ADHD

Ethnicity / Primary language spoken at home

Sibling 1:

Name and Age

Sibling 2:

Name and Age

Sibling 3:

Name and Age

Sibling 4:

Name and Age

Is your child currently accessing any other allied health services?

Please describe:

Who was seen? How long were they seen? Addressing which concerns?

Early motor development

Achievement of developmental stages - sitting, walking, talking

Early language development

Speech onset, pronunciation, ability to understand and express language

Previous Diagnoses and Assessments

Language, Occupational Therapy, Psychometric, etc

Current Medication

Prescription, supplements, vitamins, etc.

Medical History

Accidents, hospitalisation or illnesses.

Educational History

Mainstream or support class? Challenges in the classroom.

Has your child received support in the classroom?

Describe support received

Concentration / Attention

Ability to focus and sustain attention

Behaviour challenges in the classroom

E.g., Fidgeting or interrupting, distraction, inattention, etc.

Behaviour and Compliance

Concerns regarding your child's behaviour in the home. E.g., compliance with chores, frequent meltdown, withdrawn, etc.

Device access and use

E.g., Device type, time of day, duration, activity.

Friendship and Social Skills

Comment on your child's social connections and interactions

Diet and Appetite

i.e., Do they eat at least 3 meals a day, do they eat a range of meat, fruit and vegetables? Are they fussy?

Sleep

Quality of sleep, number of hours slept (wake and sleep time). Reassurance required to sleep or co-sleeping? Snoring or mouth breathing?

Activity Level

Participation in organised sport & frequency Active vs sedentary

Concerns that could impact the assessment:

E.g., Anxiety, low mood

Assessment Fees

Payment must be made in full on the day of the assessment.

Where an assessment is over two days, 50% of the payment must be made at each session.

Any exceptions to this must be raised prior to booking the assessment in.

Assessment reports willl not be issued until payment is received in full.

Date