Biographical Questionnaire
Please complete as comprehensively as possible
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1. CHILD'S DETAILS
Name & Surname *
Date of Birth *
Age *
What is the reason for referral? *
Who referred you? *
Name of current school *
In what grade is your child *
Has your child ever had to repeat a school year? *
If yes, which grade and why?
Has your child been diagnosed with any conditions? *
If yes, please indicate the diagnoses and the professionals who made the diagnoses
Is your child using any medication? *
Please indicate the name of the medication, the dosage and how long your child has been using it
Please indicate any previous therapies your child has received *
Required
How many other children are in the family? *
What is your child's position in the family (eldest/youngest etc)? *
With whom does your child live? *
Are there any other places your child stays regularly? *
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