CHILD PRE-ASSESSMENT FORM
(REF:OP\CPAF:27/2/2020)

Please complete this form so that we may provide the best possible service for your child. Please note that all information given is kept strictly confidential and will only be released with the written consent of the parent/guardian.
CHILD'S FULL NAME (As per IC/Passport) *
Your answer
GENDER *
DATE OF BIRTH *
MM
/
DD
/
YYYY
PLACE OF BIRTH & NATIONALITY *
Your answer
PRIMARY CONTACT PERSON *
MOTHER'S NAME *
Your answer
MOTHER'S MOBILE NUMBER *
Your answer
MOTHER'S EMAIL ADDRESS *
Your answer
MOTHER'S OCCUPATION *
Your answer
FATHER'S NAME *
Your answer
FATHER'S MOBILE NUMBER *
Your answer
FATHER'S EMAIL ADDRESS *
Your answer
FATHER'S OCCUPATION *
Your answer
CURRENT ADDRESS *
Your answer
NAMES & AGES OF SIBLINGS
Your answer
CHILD'S PRIMARY LANGUAGE *
Your answer
NAME OF SCHOOL & GRADE LEVEL (if the child is attending school) *
Your answer
IS THIS YOUR BIOLOGICAL CHILD? IF NO, PLEASE STATE RELATIONSHIP *
Your answer
PLEASE LIST ANY MEDICATIONS YOUR CHILD IS TAKING OR ALLERGIES YOUR CHILD MAY HAVE *
Your answer
PLEASE DESCRIBE IF YOUR CHILD HAS ANY MEDICAL ISSUES (From birth to current) *
Your answer
WHAT ARE YOUR MAIN CONCERNS ABOUT YOUR CHILD? Please rate how concerned you are regarding your child's development in the following areas: *
Not concerned
Slightly concerned
Moderately concerned
Very concerned
Communication
Fine Motor Skills (e.g. use of fingers, writing)
Coordination/ Movement
Sensory (e.g. sensitivities to certain textures/sounds, light, spinning, tiptoeing)
Social Interaction
Learning Difficulties (e.g. reading, writing)
Attention / Focus
Emotional / Behavioral (e.g. anxiety, depression, anger, aggression)
DESCRIBE YOUR CONCERNS. HOW DOES THIS AFFECT YOUR CHILD? *
Your answer
LIST OTHER SPECIALISTS YOU HAVE SEEN REGARDING THIS ISSUE (if applicable) e.g. doctor, pediatrician, psychologist, psychiatrist, learning centre, school special education teacher, TCM, etc. *
Your answer
DOES YOUR CHILD HAVE A SPECIFIC DIAGNOSIS RELATED TO YOUR CONCERN? *
IF YES, PLEASE ELABORATE.
Your answer
IS THERE A KNOWN HISTORY OF A LEARNING OR DEVELOPMENTAL DISABILITY IN YOUR FAMILY? (such as Autism/PDD, ADHD, Dyspraxia, Hearing Loss, Stuttering, Sensory Integration Disorder, etc) IF YES, PLEASE ELABORATE. *
Your answer
BASED ON THE ABOVE, WHICH SPECIALIST(S) WOULD YOU LIKE TO MEET FOR AN APPOINTMENT? *
Required
WHAT ARE YOUR CHILD'S STRENGTHS AND WEAKNESSES? *
Your answer
WHAT MOTIVATES YOUR CHILD (FAVOURITE ACTIVITIES/TOYS)? *
Your answer
PLEASE STATE ANY ADDITIONAL INFORMATION OR COMMENTS YOU FEEL WOULD HELP US IN EVALUATING / PROVIDING INTERVENTION FOR YOUR CHILD?
Your answer
WHAT OUTCOME(S) DO YOU HOPE TO ACHIEVE FROM YOUR INITIAL APPOINTMENT? *
Your answer
HOW DID YOU HEAR ABOUT / WHO REFERRED YOUR CHILD TO OASIS PLACE? *
Required
MAY WE CONTACT THE REFERRER (School/Doctor/Allied Health Prof) FOR ADDITIONAL INFORMATION OR CLARIFICATION? IF YES, PLEASE PROVIDE A SPECIFIC NAME, ORGANISATION & CONTACT INFORMATION *
Your answer
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