Background Information Form

Child's Full Name *

Gender

Date of Birth *

Age

Who currently lives at home with your child?

Name

Age

Gender

Relationship to child

Does the child have any other siblings/half siblings who live elsewhere? If yes, list name, age and gender:

Custody arrangements (if applicable):

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What schools has your child attended?

SchoolOut of home care (e.g. Day Care)PreschoolPrimary SchoolHigh School

Name of School/Centre

Dates

Grades

Please describe your child’s strengths:

Please describe the concerns you have about your child:

Please write down your goals for seeing a Psychologist:

Please rate your child’s current functioning in the following areas:

Below AverageAverageAbove Average

Social

Below AverageAverageAbove Average

Emotional

Below AverageAverageAbove Average

Intellectual

Below AverageAverageAbove Average

Physical

Below AverageAverageAbove Average

Language

Below AverageAverageAbove Average

Behavioural

Below AverageAverageAbove Average

Please provide details of any previous assessments that have been carried out (e.g. cognitive assessments, speech pathology assessments, etc.)?

Test

Date

Results

Please email the results of any previous testing to cdn@cd.net.au prior to the initial consultation.

Developmental History

Were there any complications during the pregnancy or birth (e.g. maternal illness, etc)?

Term length:

FullPrematureLate

If premature/late, how many weeks?

Birth weight:

Did your child experience any issues after birth (e.g. jaundice, seizures etc)?

Describe your child’s temperament as an infant (e.g. placid, active, demanding etc):

Did your child experience difficulties in any of the following areas during infancy or early childhood?:

SocialPhysical DevelopmentCognitive DevelopmentEmotionalBehaviouralToilet TrainingDifficulty with separationSleepingEating

Please provide more detail if you have ticked one or more of the above:

At approximately what age were the following milestones achieved?

Sitting:

Crawling:

Walking:

Talking:

List any significant or traumatic events that occurred during infancy or childhood (e.g.. birth of sibling, death of family member, physical or sexual abuse, separation from parent, divorce etc):

Primary School Years:

List any difficulties during this time (e.g. social, emotional, behavioural, physical and cognitive development, difficulties starting school, or difficulties with separation):

High School Years:

List any difficulties during this time (e.g. difficulty transitioning to high school, difficulties with relationships with peers, parents or teachers, bullying, issues with academic performance, etc):

Has your child received any special education assistance?

YesNo

If yes, please provide more details:

Medical History

Does your child have any current medical conditions, illnesses or allergies?

YesNo

Details:

Has your child’s hearing been tested?

YesNo

Were any issues identified:

YesNo

Hearing details:

Has your child’s vision been tested?

YesNo

Were any issues identified?

YesNo

Vision details:

Current medications your child takes (please list all):

Name/Type of medicine

Dose

Frequency

Who prescribes this medication

Has your child previously experienced any serious injuries, illnesses, or surgery?

YesNo

If yes, provide details and approximate dates:

Family History

Is there any family history of psychological, developmental or learning difficulties?

YesNo

If yes, please provide details:

Psychological Treatment History

Has your child previously consulted a professional for any emotional or behavioural issues?

YesNo

If yes, please provide details:

Social Functioning

How does your child spend their free time?

What type of playmates does your child prefer (tick all that apply):

OlderYoungerOwn ageAll agesAdults

How many friends does your child have?

Does your child have a best friend?

YesNo

If yes, how long have they been friends:

Does your child have trouble making or keeping friends?

YesNo

If yes, please provide details:

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Perceptions of the issues

What do you think is contributing to your child’s current presenting problems (e.g. recent change of school, etc.)?

Please provide information about anything else that you think is important regarding your child:

Is there any sensitive information that you would prefer not to discuss in front of your child?

YesNo

Thank you for taking the time to complete this questionnaire.

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