Child Biographical Information Form
This form is for the purpose of gaining contextual and historical understanding of the client.This informational form is for the purpose of contracting with the client, guardian and payee .
Client Details
Name
Prefix
First Name
Middle Name
Last Name
Client ID Number
*
13-digitSA ID Number, if a foreign national, type 1111111111111
Client Date of Birth
*
/
Month
/
Day
Year
Date
Client Age
The Clients Current Age
Client Gender
*
Clint Mobile Number
*
-
Area Code
Phone Number
Client Email Adress
*
Confirmation Email
example@example.com
School(Child Minor)
*
Grade (Child Minor)
*
Address
*
Street Address
Street Address Line 2
City
State/Province
Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Marital status of (Individual or Family Unit)
*
Reason For Therapy/Assessment
Psychoeducational Assessment
Couples Counselling
Bereavement/Death
Divorce
Parental Guidance
Depression, Stress and Fatigue
Marriage Counselling
Self-esteem
Self-harm
Sexual Education and Orientation
Violence and Crime
Career Guidance
Other
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Client Biographical Information Form
The Client Biographical Information Form allows the psychologist to ascertain some prior background and context of the client. Please fill this in as comprehensively as possible, as this will be used in conjunction with the Initial Parental Interview
Home Language of Child
English
Afrikaans
Northern Sotho
Sotho
Southern Ndebele
Swazi
Tsonga
Tswana, Venda
Xhosa
Zulu
Chinese
Italian
Portuguese
German
Spanish
Other
Name, Age and Grade of All Siblings
*
Does the child have any siblings of step-siblings?
If Divorced, with whom do the children reside with?
Prefix
First Name
Middle Name
Last Name
Has your child had any form of assessment before?
*
Current Difficulties
*
Please list your concern's that require intervention
Developmental History
This section explores your child's developmental milestone and history. Please be as descriptive as possible.
Were there any problems during pregnancy or any birth complications?
*
Birth Weight
in Kilograms
At (more or less) what age did your child do the following?Sit:
number in months
months. Crawl:
number in months
months.Walk:
number in months
months.First Word:
number in months
months.First Three Word Sentence:
number in months
months.
Any feeding problems during infancy, as a toddler or at present?
*
Any sleeping problems during infancy, as a toddler or at present?*
*
Child movements rating
*
Good
Average
Poor
Fine-Motor Control
1
2
3
Gross-Motor Control
4
5
6
Control over big movements i.e. running
7
8
9
Hand dominance
*
Did your child experience any early separation difficulties or loss?
*
Intellectual and Educational Information
This section provides information about your child's learning, intellectual and schooling background.
How do you rate your child’s:
*
Good
Average
Poor
Intellectual Ability
10
11
12
Concept of Numbers
13
14
15
Long-Term Memory
16
17
18
Short-Term Memory
19
20
21
Language Development
22
23
24
Reasoning Ability
25
26
27
Comprehension
28
29
30
What nursery and/or other primary schools did your child attend (please indicate the years)?
*
Please elaborate and explain
How did your child adjust to school when he/she went for the first time?
*
Please elaborate and explain
Attitude towards school rating
*
Good
Average
Poor
Childs Attitude towards school
31
32
33
Has this attitude ever changed for some or other reason?
*
Attitude towards teacher rating
*
Good
Average
Poor
Childs Attitude towards teacher
34
35
36
Please provide some details
*
please elaborate and explain
What are your child’s current academic difficulties?
*
please elaborate and explain
If so, for what subject/s
Maths
English
Afrikaans
Zulu
Science
Economics or Accounting
Geography or History
Art
Life Orientation
Does/did your child attend any other therapy?
Occupational Therapy
Speech Therapy
Other forms of Therapy
None
Does your child have any difficulties with
Hearing or sound
Seeing or sight
Speech or spoken word
Articulation or vocalization
None
If yes, please elaborate?
What would you rate your child for?
Good
Average
Poor
Interest in stories
37
38
39
Sporting Ability
40
41
42
Leadership Ability
43
44
45
Personality
This section ascertains your child personality, strengths, vulnerabilities and coping skills.
In general, please describe your child’s Strengths:
*
please elaborate and explain
In general, please describe your child’s Vulnerabilities:
*
please elaborate and explain
In general, please describe your child’s Coping skills:
*
please elaborate and explain
Please select which personality characteristics most apply to your child. Please select at least 3.
Active
Acts with self-control
Attention-seeking
Can take the lead
Careless
Cheerful
Daydreamer
Dishonest
Domineering
Easily distracted
Easy to manage
Enthusiastic
Exceptionally tidy
Honest
Humouristic
Inclined to jealousy
Loving
Moody
Obedient
Pays attention
Quiet
Rebellious
Selfish
Sense of Responsibility
Shy
Solitary
Spontaneous
Untidy
Social Circumstances
This section ascertains your child social character and network related to interpersonal relationships and discipline within the home setting.
Who would you consider your child’s support system to be? Close friendships etc
*
In his/her interpersonal relationships, would you describe the role your child takes on as being more:
*
In his/her interpersonal relationships, would you describe the role your child takes on as being more:
*
In his/her interpersonal relationships, would you describe the role your child takes on as being more:
*
In his/her interpersonal relationships, would you describe the role your child takes on as being more:
*
How does your child respond to discipline at home?
*
please elaborate and explain
How does your child respond to discipline from others?
*
please elaborate and explain
Whose authority does your child accept more easily?
*
How does your child relate to:
*
Well
Indeffirent
Not Well
How does your child socialize generally
46
47
48
How does your child relate to his/her father
49
50
51
How does your child relate to his/her siblings
52
53
54
How does your child relate to his/her teachers
55
56
57
How does your child relate to his/her peers
58
59
60
How does your child prefer to play?
*
How does your child spend his/her leisure time?
*
please elaborate and explain
As a family, how do you spend your leisure time?
*
please elaborate and explain
Do Both Parents work?
*
What jobs do both parents do?
*
please elaborate and explain
Medical Information
This section relates to your child's medical history, sleeping, eating and energy patterns and medication.
In your opinion, is your child’s general health?
*
Is your child currently on any medication?
*
My child's sleeping patterns are
Please Select
Normal
Erratic
*
My child's eating patterns are
Please Select
Normal
Erratic
*
My child's energy patterns are
Please Select
Normal
Erratic
*
My child's concentration and attention patterns are
Please Select
Normal
Erratic
*
Please supply information regarding your child’s sleeping patterns / appetite / energy levels / concentration and attention. Is there anything you are concerned about in these areas?
Emotions
This section relates to your child's emotional standing, their anxieties and feelings.
How would you describe your child in terms of his/her predominant emotions and feelings at present?
*
please elaborate and explain
Does your child have any fears that you are aware of? If so, what are they?
*
please elaborate and explain
Does your child show signs of being anxious? If so, what do you think causes the anxieties?
*
please elaborate and explain
Please select any of the following currently applies to your child:
Sleeplessness
Sleepwalking
Nightmares
Fear of the dark
Easily frightened
Nail biting
Exceptional need for pampering
Considerable self-confidence
Independent
Dependent
Fluctuating emotions
Thumb sucking
Tense
Temper outbursts
Need for cuddling teddy, blanket etc
Phobias
None
Please elaborate and explain
*
please elaborate and explain
Traumatic Events
This section relates to any events which may have caused trauma to your child as a result of that historical or lingering event.
Is there anything that you have not mentioned above which you would like to add?
*
If yes, please elaborate?
*
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