CHILD PRE-ASSESSMENT FORM
Please complete this form to the best of your ability so that we may provide the best possible service for your child. If your child has any recent reports completed by other health professionals (psychologist, speech language pathologist, occupational therapist, IEP, etc.), kindly bring copies of these with you at your first appointment or you may fax/email them in advance. Please note that all information given is kept strictly confidential and will only be released with the written consent of the parent/guardian. We look forward to meeting you and your child!
BACKGROUND INFORMATION
CHILD'S NAME *
Your answer
NAME CHILD PREFERS TO BE CALLED
Your answer
GENDER *
DATE OF BIRTH *
MM
/
DD
/
YYYY
PLACE OF BIRTH *
Your answer
NATIONALITY *
Your answer
CONTACT DETAILS
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
HOME PHONE NUMBER
Your answer
PRIMARY CONTACT PERSON (OTHER THAN PARENTS) please indicate name, contact number & email address where possible
Your answer
FAMILY & SCHOOLING DETAILS
NAMES & AGES OF SIBLINGS
Your answer
CHILD'S PRIMARY LANGUAGE *
Your answer
LANGUAGE(S) SPOKEN AT HOME *
Your answer
NAME OF SCHOOL & GRADE LEVEL (if the child is attending school) *
Your answer
CONCERNS
DESCRIBE YOUR CHILD IN GENERAL? *
Your answer
WHAT ARE YOUR MAIN CONCERNS ABOUT YOUR CHILD? *
Your answer
HOW DOES THIS ISSUE AFFECT YOUR CHILD? *
Your answer
DOES YOUR CHILD HAS A SPECIFIC DIAGNOSIS RELATED TO YOUR CONCERN? *
Required
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) *
Required
IF YES, PLEASE ELABORATE
Your answer
WHO REFERRED YOUR CHILD TO OASIS PLACE? *
Your answer
MAY WE CONTACT THE REFERRER FOR ADDITIONAL INFORMATION OR CLARIFICATION? *
Required
IF YES, PLEASE PROVIDE A SPECIFIC NAME, ORGANISATION (if appropriate) & CONTACT INFORMATION
Your answer
LIST OTHER SPECIALISTS YOU HAVE SEEN REGARDING THIS ISSUE (e.g.doctor, psychologist, etc) *
Your answer
WHAT ARE YOUR CHILD'S STRENGTHS AND WEAKNESS? *
Your answer
WHAT MOTIVATES YOUR CHILD (FAVOURITE ACTIVITIES/TOYS)? PLEASE DESCRIBE *
Your answer
PLEASE PROVIDE DETAILS OF ANY EVALUATIONS OR THERAPIES YOUR CHILD HAS RECEIVED IN THE PAST
Your answer
AREAS OF CONCERN
Please rate how concerned you are regarding your child's development in the following areas. *
Not concerned
Slightly concerned
Moderately concerned
Very concerned
Extremely 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)
PLEASE INDICATE ANY OTHER AREAS OF CONCERN THAT HAVE NOT BEEN INCLUDED ABOVE
Your answer
Based on the above concerns, which specialist would you like to meet for an appointment? *
HEALTH HISTORY
IS THIS YOUR BIOLOGICAL CHILD? *
Required
WAS YOUR CHILD BORN AT FULL TERM OR PREMATURELY? If premature, please provide details (number of weeks, etc) *
Your answer
DELIVERY
PLEASE LIST ANY SPECIFIC ISSUES DURING PREGNANCY, LABOUR OR BIRTH
Your answer
PLEASE DESCRIBE YOUR CHILD'S HEALTH DURING HIS OR HER EARLY MONTHS OF LIFE *
Your answer
PLEASE LIST ANY PROBLEMS WITH YOUR CHILD'S EATING, SLEEPING OR BEHAVIOUR *
Your answer
PLEASE DESCRIBE IF YOUR CHILD HAS ANY MEDICAL ISSUES *
Your answer
PLEASE LIST ANY MEDICATIONS YOUR CHILD IS TAKING *
Your answer
PLEASE LIST ANY ALLERGIES YOUR CHILD MIGHT HAVE *
Your answer
PLEASE LIST ANY SPECIAL DIET / SUPPLEMENTS YOUR CHILD IS ON *
Your answer
HAS YOUR CHILD HAD HIS/HER HEARING TESTED PREVIOUSLY?
IF YES, PLEASE PROVIDE DETAILS OF THE LATEST HEARING TEST
HAS YOUR CHILD HAD HIS/ HER VISION TESTED PREVIOUSLY?
IF YES, PLEASE PROVIDE DETAILS OF THE LATEST VISION TEST
WEARS GLASSES
PLEASE STATE ANY ADDITIONAL INFORMATION OR COMMENTS YOU FEEL WOULD HELP US IN EVALUATING / TREATING YOUR CHILD?
Your answer
WHAT OUTCOME(S) DO YOU HOPE TO ACHIEVE FROM YOUR INITIAL APPOINTMENT? *
Your answer
HOW DID YOU HEAR OF OASIS PLACE? *
Required
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