Assessment Questionnaire

The following questionnaire is designed to assist with gathering information to understand your

young persons’ unique circumstances. Please be as detailed as possible.

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Young person's full name

Date of birth

Age

Sex

Person completing this questionnaire

Relationship to young person

Today's date

Family members and household/s composition:

Name

Relationship to young person

Occupation

Age

Are there any legal proceedings currently occurring?

YesNo

If yes, please provide details

Custody arrangements if applicable

Are there any court orders in place?

YesNo

If yes, please provide a copy of court orders to CDN.

Is your young person currently under the care of other professionals at the Child Development Network?

YesNo

If yes, who?

Describe your major concerns about your young person at this present time.

When were these problems first noticed?

Please describe your young person’s strengths:

What activities does your young person most like to spend their time doing? Please describe any special skills or areas of particular interest in as much detail as possible.

Please list your young person’s least favourite activities:

How does your young person respond to sensory input and changes in their surroundings, including any preferences or aversions?

Technology:

Please list any devices such as mobile phones, tablets, or gaming consoles your young person has access to:

How many days per week do they have access to devices and gaming?

On average, how many hours per day do they play on devices or gaming?

Do you experience any difficulties if restrictions are placed on access to devices or games?

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Developmental History:

Were there any concerns or difficulties during pregnancy?

YesNo

If yes, please describe:

Was the birth mother taking any medications during pregnancy?

YesNo

If yes, please describe:

Term length

Full termPrematureLate

If premature/late, how many weeks?

Birth weight

Any complications during birth? If yes, please describe:

Did your young person experience any complications following birth? If yes, please describe:

The following is a list of infant and early childhood developmental milestones. Please indicate the approximate age when your young person was able to do the following:

Showed response to parent

Rolled over

Crawled

Babbled

Sat unaided

Spoke several words together

Dressed self

Fed Self

Rode bicycle

Toilet trained – daytime

Toilet trained - nighttime

Parenting Styles:

There is a lot of pressure to be the “best” parent, but there are many different styles of parenting. Describe your approach to parenting including expectations of your young person, how conflict/boundary setting is managed, and reward systems.

Social and Emotional Development:

Please tick if you currently observe/have concerns for any of the following:

Differences in CommunicationPreferring to play alone Does not get along well with siblings Does not get along well with peersAggressive behaviourIs shy or timidIs more interested in objects than peopleEngages in dangerous behavioursHas particular fearsSoils self or their bedEasily frustrated / Angers quicklyFrequent nightmaresDifficulties sleepingEats poorlyFrequently in trouble at home/schoolAvoids things that cause anxietyIntense interestsFixated on gaming or technologyPoor behaviour if gaming not availableAvoids / refuses school

Education:

What schools or educational facilities has your young person attended? Please list all below:

Daycare

Kindergarten

Primary School

High School

Please list any difficulties your young person has experienced since commencing their formal education Eg. Separation anxiety at drop off, learning difficulties, social difficulties.

Has your young person been given any additional supports at school?

YesNo

If yes, please provide details:

Is your young person achieving at or above the expected level in their most recent school report?

YesNo

If no, please list what areas they are experiencing difficulty with?

Medical History:

Does your young person have any current medical diagnosis?

YesNo

If yes, please provide details:

Does your young person take any medications?

YesNo

If yes, please list medications and reasons:

Has your young person previously experienced any serious illnesses or injury?

YesNo

If yes, please provide details:

Is there any suspected or formally diagnosed family history of psychological, developmental or learning differences?

YesNo

If yes, please provide details including whether suspected/self-identified or formally diagnosed.

Treatment History:

Have you previously consulted a professional for psychological or behavioural concerns?

YesNo

If yes, please provide details including any diagnosis that have previously been given.

Has your young person previously, or currently, accessed other allied health supports outside of CDN? (E.g. Dietician, Occupational Therapy etc).

YesNo

If yes, please provide details:

What treatment approaches have you previously found helpful or unhelpful? Please provide details.

Is there anything else relevant to your young person or family circumstances that I should be made aware of?

YesNo

If yes, please provide details below.

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Thank you for your time.

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