Intake Assessment

1

Child Name* This field is required.

2

Child Date of Birth* This field is required.

Date

3

Child Current Address* This field is required.

4

Primary Contact Number* This field is required.

Area Code

Phone Number

5

Contact Person Name* This field is required.

6

Contact Person's Relationship to Child* This field is required.

7

Current School* This field is required.

8

Grade/Year* This field is required.

9

Mother's Name * This field is required.

10

Mother’s Name* This field is required.

11

Mother's Phone Number* This field is required.

12

Mother's Email* This field is required.

13

Mother's Occupation* This field is required.

14

Father's name* This field is required.

15

Father’s Name* This field is required.

16

Father's Phone Number* This field is required.

Area Code

Phone Number

17

Father's Email* This field is required.

18

Father's Occupation* This field is required.

19

Parents’ Marital Status

20

Other Children in the Household* This field is required.

21

Please briefly describe your child’s current challenges starting with the most serious* This field is required.

22

How long ago did the challenges begin? How old was your child? Was there a precipitant? Were there any major stresses happening in the family at the time the challenges began?* This field is required.

23

List any complications at birth and delays in development or difficulties when child was an infant/toddler* This field is required.

24

Was there anything unusual, different, or difficult about your child during the first 12 months of life?* This field is required.

25

Describe any prior assessment/therapy child has received* This field is required.

26

Where do you live?* This field is required.

27

Who lives at home with you? How long have you lived there ?* This field is required.

28

Is this stable accommodation for you?* This field is required.

29

How many times has your family moved during your child’s lifetime? Please explain your moves and reasons for moving. How did your child adapt to moving?* This field is required.

30

Have there been any recent stresses in the family? Please explain* This field is required.

31

Has anyone recently left the family or passed away? Please explain* This field is required.

32

Has anyone recently joined the family? Please explain* This field is required.

33

Have there been any recent financial changes (good or bad)? Please explain* This field is required.

34

How would you describe your relationship with your partner? (Choose one)* This field is required.

Cold/distant

Stormy/argumentative

Loving/close

Tolerant/put up with each other

Abusive/ physical and/or verbal fights

35

How would you describe the mother/child relationship? (Choose one)* This field is required.

Cold/distant

Stormy/argumentative

Loving/close

Tolerant/put up with each other

Abusive/ physical and/or verbal fights

36

How would you describe the father/child relationship? (Choose one)* This field is required.

Cold/distant

Stormy/argumentative

Loving/close

Tolerant/put up with each other

Abusive/ physical and/or verbal fights

37

Does anyone in your family have any mental health issues or problems with drugs/alcohol or other addictive substance or behavior?* This field is required.

YesNo

38

How does your child’s challenges affect his or her relationship with brothers , sisters or relatives ?* This field is required.

40

How does your child's challenges affect his or her relationship with you (and a parenting partner if present)?* This field is required.

41

Is there anything else we should know about your family?* This field is required.

42

What types of discipline do you use when your child misbehaves?* This field is required.

43

Can you describe a recent incident where you had to discipline your child? What was the behaviour, and what consequence did you apply?* This field is required.

44

In the past month, approximately how much time did your child spend on screens per day?* This field is required.TV, video games, phones, tablets, and/or computers

0 hours a day

1-2 Hours

3-4 Hours

4-6 Hours

45

Does your child become angry, agitated, or frustrated when screen time is over?* This field is required.

Never

Rarely

Sometimes

Often

Very Often

46

Does your child's screen time have an impact on family relationships?* This field is required.

YN

47

Do you find that your child's screen time has an impact on his/her attitude and behavior?* This field is required.

49

What applications does your child enjoy during screen-time* This field is required.

50

Does your child respond to his/her name ? * This field is required.

YesNo

51

Does your child prefer to play alone or with others?* This field is required.

52

How does your child understand and respect personal space in social interactions?* This field is required.Briefly explain if applicable

53

How often does your child make eye-contact during conversations ?* This field is required.

54

Is your child able to handle turn-taking during games or conversations ?* This field is required.

55

Does your child find it difficult to share toys or other resources with others ? * This field is required.

56

Who are his/her closest friends? How does he/she know them?* This field is required.

57

How well does your child recognise and respond to different facial expressions, and emotional states? (e.g., easily recognises emotions, sometimes confused)* This field is required.

58

How does your child react to compliments directed towards him/her ? ((e.g., accepts graciously, seems unsure, dismisses them)* This field is required.

59

Does your child return compliments directed towards him/her ? * This field is required.

60

Does your child seek assistance or guidance when he/she needs it ? * This field is required.Briefly describe how they communicate their need if applicable.

61

Does your child understand jokes and sarcasm ?* This field is required.Briefly describe if applicable

62

Does your child get picked on or teased? If “yes” why and how does she/he handle it?* This field is required.

63

Is there anything we need to know about your child's social environment?* This field is required.

64

How does your child's challenges affect his or her relationships with playmates* This field is required.

66

Please tick the statements that apply to your child's Social skills while engaging in conversations.

67

Describe your child’s attitude toward school* This field is required.

68

Describe your child’s behaviour at school* This field is required.

69

Has your child ever refused to go to school? If “yes”, please explain* This field is required.

70

Have your child’s grades changed over time? If “yes”, please explain* This field is required.

71

Has your child been evaluated for Learning Disabilities? If “yes”, please describe the results* This field is required.

72

How does your child's challenges affect his or her academic progress at school* This field is required.

73

How does your child's challenges affect his or her self-esteem & emotional well-being* This field is required.

74

What is your child's choice of spoken language ? Does he/she have other languages ? Please explain* This field is required.

75

Languages and proficiency* This field is required.

76

Please tick the statements that can be applied to your child's language level

77

Does your child display signs of echoing (the action of repeating what someone else says)* This field is required.

78

Does your child display signs of scripting ( delayed repetition of lines from T.V. shows, videos, or previously heard language repetitively)* This field is required.

79

Does your child display signs of lisps, dropping of consonants, or struggles to articulate words clearly * This field is required.

80

Describe your child's strengths and skills* This field is required.

81

What are your child's hobbies?* This field is required.

82

Describe the strengths of the support system involved with the child* This field is required.

83

Describe your child's favourite part of his/her routine * This field is required.

84

Describe the level of independence your child has when carrying out his/her routine* This field is required.

85

List all the objects/tools that brings comfort to your child* This field is required.

86

What kinds of interventions have been tried? Have you tried medications, seen other therapists, used any “non-traditional” treatments?* This field is required.

87

Medical History* This field is required.

88

List any medications your child is taking and describe its purpose:* This field is required.

89

Briefly describe your child's bedtime routine* This field is required.

90

Briefly describe your child's routine when they wake up* This field is required.

91

Does your child nap* This field is required.

92

Does your child have a fixed wake and sleep schedule ?* This field is required.

YesNo

93

Please Check the items in which your child can perform independently.

94

Does your child engage in any self-Injurious behaviour ?* This field is required.Brief description if applicable

95

Does your child tend to wander away from adults or secure locations? (Elopement)* This field is required.Brief description if applicable

96

Does your child tend to intentionally cause harm or display aggressive behaviours towards other ? * This field is required.Brief description if applicable

97

Is your child enrolled in extra-curricular activities ?* This field is required.

98

Has your child been displaying temper tantrums or was difficult to control the past month ? * This field is required.Please state the frequency and estimated duration of the tantrum.

99

Does your child display abilities of self soothing ?* This field is required.

100

Does your child make negative statements about him/herself? What are they?* This field is required.

101

Does your child ever feel guilt or remorse for wrong doings? If “yes” how does he/she show it?* This field is required.

102

Does your child display low tolerance towards transitioning from one activity to another ?* This field is required.Brief description if applicable

103

Does your child display signs of hopelessness, negative self-talk, or self-harm ? * This field is required.Brief description if applicable

104

Has your child ever experienced sensory overload in a crowded or noisy environment?* This field is required.

YesNo

105

What strategies does your child use to cope with sensory overload or discomfort?* This field is required.Brief description if applicable

106

Tactile needs: Does your child seek or avoid certain textures ? ((e.g., soft, rough, sticky)* This field is required.Brief description of seeking or avoidance if applicable

107

Olfactory Sensitivity: How does your child respond to different smells ? (e.g., enjoys certain smells, dislikes strong odors, indifferent)* This field is required.Brief description of seeking or avoidance if applicable

108

Visual Sensitivity: Does your child display signs of seeking/avoiding specific visual preferences (e.g., feeling anxious in brightly lit environments, discomfort from shiny surfaces, overstimulation from certain colours or patterns)* This field is required.Brief description of seeking or avoidance if applicable

109

Auditory needs: Are there specific sounds that your child particularly enjoys or dislikes?* This field is required.Brief description of seeking or avoidance if applicable

110

Does your child identify and communicate feelings of physical pain (e.g., tripping and falling, bumping head, bumps, scrapes)* This field is required.Brief description of seeking or avoidance if applicable

111

Working memory: How well does your child remember and follow multi-step instructions?* This field is required.

112

Cognitive Flexibility: How does your child handle changes in routine or unexpected events?* This field is required.

113

Task Initiation: How quickly does your child begin tasks when asked?* This field is required.

114

Self-Monitoring: How aware is your child of their own behaviour and its impact on others?* This field is required.

115

Time Management: How does your child manage their time for completing tasks?* This field is required.

116

Planning and Organisation: How effectively does your child plan and organise tasks or activities?* This field is required.

117

Gross Motor Skills: Please Check the items in which your child can perform independently.

118

Fine Motor Skills: Please Check the items in which your child can perform independently.