• 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

  • Client Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Client Gender*
  •  -

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  • Grade (Child Minor)*
  • Marital status of (Individual or Family Unit)*
  • Reason For Therapy/Assessment

  • 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
  • Has your child had any form of assessment before?*

  • 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?*
  • At (more or less) what age did your child do the following?Sit: months. Crawl: months.Walk:      months.First Word:   months.First Three Word Sentence:   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*
    Rows
  • 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:*
    Rows
  • Attitude towards school rating *
    Rows
  • Attitude towards teacher rating *
    Rows
  • If so, for what subject/s
  • Does/did your child attend any other therapy?
  • Does your child have any difficulties with
  • What would you rate your child for?
    Rows

  • Personality

    This section ascertains your child personality, strengths, vulnerabilities and coping skills.
  • Please select which personality characteristics most apply to your child. Please select at least 3.

  • Social Circumstances

    This section ascertains your child social character and network related to interpersonal relationships and discipline within the home setting.
  • 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:*
  • Whose authority does your child accept more easily?*
  • How does your child relate to: *
    Rows
  • How does your child prefer to play?*
  • Do Both Parents work?*

  • 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   *   My child's eating patterns are   *My child's energy patterns are   *   My child's concentration and attention patterns are   *   

  • Emotions

    This section relates to your child's emotional standing, their anxieties and feelings.
  • Please select any of the following currently applies to your child:

  • 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?*
  • Should be Empty:
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