Questionnaire

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Questionnaire

Dear Parent/Caregiver,

This questionnaire will help us learn about your child's communication skills.

Please Complete the questionnaire.

Tick all behaviours that your child has previously exhibited or currently exhibits.
Please note, that we require your email to send you a copy of your answers.
We also require your name and phone number to be able to contact you to set a first appointment.
All info gathered in this form is private and only the therapist and parents would have access to it...
Thank you!

Email *

Your Name: *

Your Phone Number: *

Your Relationship to child: *

Mother

Father

Other:

Part 1:

Information about who your child spends time with and how he or she spends the time.

Child's name (First Name, Middle Name, Last Name): *

Date of Birth: *

Please use the name of the month instead of its number for less confusion.

e.g.: March 2nd 2019, or 2 March 2019

Gender: *

Male

Female

Does your child go to a nursery or school? *

Nursery

School

Stays at home

Name of the nursery or school: *

Home Address: *

My child has:

Older brothers

Older sisters

Younger brothers

Younger sisters

No siblings

Required

List of the Family Members living in the same house as your child (Parents and Siblings)

(Name, Age for minors, Relationsip

e.g. Adam, Father

Lilly, Mother

Sam, 11, Brother

Ada, 8, Sister...)

The language(s) spoken at home to my child is/are:

Arabic

Bengali

English

French

German

Hausa

Hindi

Igbo

Italian

Mandarin

Spanish

Urdu

Yoruba

Other:

Required

The language(s) spoken in community to my child is/are:

Arabic

Bengali

English

French

German

Hausa

Hindi

Igbo

Italian

Mandarin

Spanish

Urdu

Yoruba

Other:

Required

The language(s) spoken in nursery/school to my child is/are:

Arabic

Bengali

English

French

German

Hausa

Hindi

Igbo

Italian

Mandarin

Spanish

Urdu

Yoruba

Other:

Required

My child spends most of the day at:

Home

Nursery/School

Other:

When at home, my child spends time with:

Mother

Father

Siblings

Other Family Members (grandparents, cousins...)

Nanny

Other:

Required

When watching television, my child likes to watch:

Children’s programmes (e.g. Sesame Street)

Cartoons (e.g. Pepa Pig)

Movies (e.g. Finding Nemo, Toy Story)

Other:

Required

When at home, my child usually:

Watches Television

Plays with adults

Plays with other children

Plays independently

Other:

Required

Please specify the amount of hours per day the child spends doing each of the activities you picked above (e.g. plays with adults: 1 hr/day, plays with other childred: 2hr/day...):

Part 2:

Information about your child's communication and play behaviours.

Please list the toys that your child likes and might interact with the most:

When playing with other children, my child sometimes:

Plays beside other children without sharing his or her toys

Plays with other children by following what they do or say

Plays with other children by telling them what to do

Plays with other children by sharing toys and talking

My child does not play with other children

Required

When playing, my child:

Shakes and bangs objects (e.g. shakes a rattle, bangs a wooden spoon)

Plays simple games with me (e.g. peek-a-boo, pat-a-cake)

Plays with toys appropriately (e.g. rolls ball, stacks blocks, makes stuffed dog walk and bark)

Uses toys in pretend play (e.g. uses a straw as a sword, pretends blocks are biscuits)

Plays with two or more toys together (e.g. stacks two or more blocks, rolls/pushes a car into stacked blocks)

Acts out familiar situations (e.g. dresses a doll, makes a doll drive a car, pretends to eat and drink from toy plates and cups)

Acts out unfamiliar situations (e.g. flies a doll to the moon, walks a stuffed animal through the jungle)

Required

My child pays attention to what's happening around him or her. For example, my child:

Reacts to sounds (e.g. startles when a door is slammed, looks up when the doorbell rings)

Looks up from what he or she is doing when I call his or her name

Looks at people who are talking

Looks for food that's fallen from his or her high chair

Looks toward where I'm pointing when I say, Look at the____

Other:

Required

My child enjoys attention. For example, my child:

Smiles when I talk to him or her

'Talks' when I talk to him or her (e.g. coos, gurgles, says sounds like ma, dada, ai-yee)

Takes turns talking with me using sounds or words

Invites me to play with him or her (e.g. deliberately drops a toy from the high chair to be picked up, touches me and runs to play 'catch me', brings me a toy or book)

Required

My child follows my directions when l:

Doesn’t follow my directions

Use gestures (e.g. hold out my hands to pick him or her up, wave bye-bye)

Say words paired with gestures (e.g. say no-no while shaking head, say look while pointing.)

Say words and simple phrases (e.g. stop, wait, come here, show me)

Say one-part directions (e.g. get your blankie, give me a kiss, eat your biscuit)

Say two-part directions (e.g. find your shoes and bring them here, get your blankie and lie down, get your spoon and eat your ice cream)

Other:

Required

My child tells me how he or she feels and what he or she wants. For example, my child:

Doesn’t tell me how he she is feeling

Uses different vocalisations to express himself or herself (e.g. has different cries, screams when angry, coos when happy, whimpers when tired)

Points to things he or she wants (e.g. points to a toy, biscuit, bottle)

Gestures (e.g. lifts arms when he or she wants to be lifted up, shakes his or her head to mean no)

Uses physical actions (e.g. takes me to the fridge, crawls into my lap, puts a toy in my hand)

Says specific sounds for things (e.g. ba for bottle, ma for mummy, uh for pick me up)

Says specific words for things (e.g. no, bye-bye, night-night, more)

Speaks in phrases (e.g. no night-night, more bikkie, want that)

Speaks in sentences (e.g. I want it. What's that? I go potty.)

Other:

Required

My child says words. For example, my child says:

Doesn’t say words yet

Family names (e.g. mummy, dada, nana, grandpa, brother’s or sister's name)

Animals (e.g. pet's name, dog, kitty, bird, fish)

Food (e.g. milk, juice, biscuit, apple, snack)

Toys (e.g. ball, dolly, balloon)

Daily routines (e.g. go bye-bye, eat, bath, night-night)

Body parts (e.g. eye, nose, mouth, hand)

Clothing (e.g. shoe, sock, shirt)

Other:

Required

My child's speech is understood by household family members (e.g. mother, father, brother, sister)

Usually

Sometimes

Rarely

My child's speech is understood by other family members (e.g. grandparents, aunts, uncles, cousins)

Usually

Sometimes

Rarely

My child's speech is understood by care providers (e.g. childminder, early years teacher)

Usually

Sometimes

Rarely

My child's speech is understood by familiar people (e.g. neighbours, friends)

Usually

Sometimes

Rarely

My child's speech is understood by unfamiliar people

Usually

Sometimes

Rarely

A copy of your responses will be emailed to the address you provided.

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