Palm Tempelton Parent Questionnaire
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Email *
Child's Name *
Child's Date of Birth *
MM
/
DD
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YYYY
Parents' Particulars
Mother’s Name *
Father’s Name *
Siblings Names & Ages
Who referred you to Palm Tempelton Learning and VAK Centre?
Position of referring person (e.g. Paediatrician, Psychologist )
Your Concerns
State the main reasons and issues that prompted you to seek professional help *
Describe what your child is having difficulties with and in what situations *
Your level of concern for your child
Indicate the rating which best describes your level of concern for your child. Please include comments and information you consider relevant.
*
Not at all
A little
Moderately
Quite a lot
Extremely
Mother
Father
Describe what you would like help with *
Your Child's Qualities
Describe your child’s personality. Tell us his / her special qualities.
List what your child does well. Include subjects and activities he/she does well in and takes pride in.
List your child’s interests.
Support for Learning
Outline support (if any) that your child has received or is receiving both within and outside of school (e.g. tutor for reading and maths). Please indicate approximate dates.
Pregnancy & Birth
Your pregnancy *
Please provide any comments (if any) with regard to your pregnancy
Your child’s birth & postnatal period *
Please provide any comments (if any) with regard to your child's birth & postnatal period
Length of Pregnancy *
Number of weeks premature (if applicable)
Your child’s birth weight *
Early Development
Your child’s first year (e.g. settling; feeding; weight gain) *
Please provide any comments (if any) with regard to your child's first year
Motor development (e.g. walking; running; jumping) *
Please provide any comments (if any) with regard to your child's motor development
Language development (e.g. using words; understanding others; talking) *
Please provide any comments (if any) with regard to your child's language development
Social Development (e.g. smiling & interacting with others; playing with other children; making friends) *
Please provide any comments (if any) with regard to your child's social development
Learning skills (e.g. understanding concepts of colour or numbers; drawing; alphabet) *
Please provide any comments (if any) with regard to your child's learning skills
Family History
Family members (mother, father, grandparents, siblings, aunts, uncles) with similar learning problems to your child *
Family members (mother, father, grandparents, siblings, aunts, uncles) with different developmental, physical, learning, social, or emotional problems to your child *
Developmental History
Please rate or describe the following (add comments if you experienced concerns)
Health Status
Hearing *
Please provide any comments (if any) with regard to your child's hearing
Vision *
Please provide any comments (if any) with regard to your child's vision
Previous accidents, injuries, or serious illnesses *
Please list and describe previous accidents, injuries or serious illnesses (if any)
Current health *
Please describe your child's current health status
Professional Services
Please tick the relevant box(es)
Currently Attending
Attended in the past
Paeditrician
Child Psychiatrist
Psychologist
Speech Pathologist
Physiotherapist
Occupational Therapist
Social Worker or Counsellor
Other
Professionals Seen
Please provide the names and approximate dates of professionals seen (if applicable).
Paediatrician - Name and approximate date(s) seen
Child Psychiatrist - Name and approximate date(s) seen
Psychologist - Name and approximate date(s) seen
Speech Pathologist - Name and approximate date(s) seen
Physiotherapist - Name and approximate date(s) seen
Occupational Therapist - Name and approximate date(s) seen
Social Worker or Counsellor - Name and approximate date(s) seen
Other - Name and approximate date(s) seen
Educational Services
Please tick the relevant box(es)
Currently Attending
Attended in the past
School Guidance Officer
Learning Support Teacher
Tutor
Other
Please describe your expectations for this referral. *
Questionnaire completed by:
Please provide us with your contact details
Name and Surname *
Day time telephone number *
After hours telephone number *
Thank you for your time in completing this questionnaire.
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