Child Pre-assessment Questionnaire

Psychology Pre-Assessment Questionnaire
Parent Name*

First NameLast Name
Contact Phone Number*

Area Code or first 2 digitsPhone Number
Email*
example@example.com
Address

Street Address

Street Address Line 2

SuburbState

Post CodeCountry
Child's Details
Child's Name*

First NameLast Name
Child's Date of Birth*

DayMonthYear
Date
School attended*
Child's Year Level at School*
Has your child had an educational assessment with a psychologist within the last 24 months? (It may not be possible to reassess children within this timeframe.)*

YesNo
Does your child identify as Aboriginal or Torres Straight Islander?*

YesNo
Is your child under the Guardianship of the Minister?*

YesNo
Are there any custody orders in place for the child on this form?*

YesNo
NOTE: Separated Families

Your psychologist is entitled to assume that you, the presenting parent, have parental responsibility, or are a legal guardian of the child participating in the assessment. A consent form will need to be signed by both parents before the assessment unless there are custody orders naming one parent as having sole parental responsibility or other exceptional circumstances apply. Please contact SPELD SA if you have any questions regarding this.
Vision and Hearing Test

Before any diagnosis of a learning difficulty such as dyslexia can be made it is important a vision and hearing test is conducted to ensure another condition is not contributing to their struggle to learn.
Date of last HEARING test*

DayMonthYear
Date
Date of last VISION test*

DayMonthYear
Date
Does your child wear glasses or contact lenses?*

YesNo
Does your child wear hearing aids?*

YesNo
Do you have any concerns about their hearing or sight?*
For what purpose are you seeking an assessment?*
Areas of Difficulty

Please provide a brief description about the difficulties your child is having in any of the following areas:
Reading
Spelling
Handwriting
Written Expression
Maths
Copying
Attention or concentration
Memory - short or long term
Organisational Skills
Is there a family history of a learning difficulty?*

YESNO
If you answered YES to the previous question please provide details:
(for example parent or grandparent has dyslexia)
Intervention

A diagnosis of dyslexia, dysgraphia or dyscalculia can only be given to your child if they have had a least six months of appropriate targeted intervention to address their difficulties.

Targeted intervention is used when a child displays difficulties with literacy or numeracy and they are placed into a small group for focused remedial instruction, or receive private tuition, to target their area of weakness.

Examples of intervention programs are:

Sounds Write
Jolly Phonics / Jolly Grammar
Read Write Inc (Fresh Start)
Specialist Tutor
Toe by Toe
MiniLit
Alpha to Omega
Reading freedom
MLC
MultiLit
Little learners Love Literacy
Reading and Spelling Mastery
Playberry
PLD
Please name and describe the targeted intervention program(s) your child has been given and note how many months it/they have run for:*
If unsure, please ask your school.
Has your child had any intervention from other specialists?

Speech PathologistPsychologistOccupational TherapistPaediatricianOther
If your child has previously had a Psychological Assessment what was the date of that assessment:

DayMonthYear
Date
Has your child been diagnosed with any specific conditions?*

YESNO
If you answered yes please provide details of the specific conditions here:
If you have any other details you think may be relevant, please provide them here:
Preferred location for assessment *

Frewville (259 Glen Osmond Road)Online
How did you learn about SPELD SA?

SPELD SA websiteSocial MediaGoogle / Internet searchFriendSchoolOther
Submit Form

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Psychology Pre-Assessment Questionnaire