Literacy Care Parent Questionnaire

Please Read Before Completing Questionnaire

Thank you for taking the time to answer the following questions. The information you provide about your child is essential.
The Questionnaire is divided into four sections. If you have been referred by a practitioner at the CDN then only complete Sections 3 and 4. If you are new to CDN please complete all four sections.
Please ensure this questionnaire is submitted along with the Teacher Questionnaire.

SECTION 1: PERSONAL DETAILS

Child's Full Name

Gender

MaleFemaleOther

Please State

Date of Birth

Parent/Guardian 1 Details

Full Name

Contact Number

Email Address

Occupation

Parent/Guardian 2 Details

Full Name

Contact Number

Email Address

Occupation

If Parents/Guardians are separated, please indicate (✓)

How far from the CDN does the child live (or go to school) in Travel Time

School

Year of Schooling (incl Prep)

Grade

Age in Years

Months

Please tick (✓) if you would like to receive Literacy and Learning information from Dr Jason McGowan and the Literacy Foundation for Children. No more than 4 emails per year.

SECTION 2: Referral Information, Existing Diagnosed Conditions and Medication

Were you referred by a clinician who is at CDN?

YesNo (Complete SECTION 2)

If yes, who was the clinician and what was the main reason you saw them?Go to Section 3

Name of referring clinician

Do you have a referral letter or report?

YesNo

(Please note: a referral letter is not required but please bring referral letter/report if you have one)

What was the main reason you saw the referring clinician?

Do you intend seeing another clinician at the CDN

YesNo

If yes, who?

When do you expect to see this professional?

If you have not been formally referred by a CDN or external clinician, how did you learn about the services of Literacy Care and the Child Development Network?

Other (Please comment)

Diagnosed Conditions and Medications

Other Diagnosed Conditions

Is the child on any medication relative to learning or behaviour?

YesNo

If yes, please give details:

SECTION 3: LITERACY AND LEARNING QUESTIONS

Strengths and Interests?

Please write a short comment on the following:

Organisational Skills

Ambitions

Non-Academic Interests

Social skills relating to family

Social skills relating to friends

Questions, Concerns, Outcomes

What outcome(s) would you like Literacy Care to achieve for your child?

If you have ticked one (or more) for the above, please briefly explain

Hereditary Factors

Does anybody in the family (siblings, parents, grandparents, aunts, etc have problems similar to, or the same as your child?

YesNo

If yes, please briefly explain

Does anybody in the family (siblings, parents, grandparents, aunts, uncles etc) have different problems, of a developmental, learning, behavioural, emotional or psychiatric nature?

YesNo

If yes, please briefly explain

Previous Professional Involvement and Management

Clinician

Currently

In the Past

Name

Academic and Scholastic Interventions and Information

Please name/describe all educational programs and or interventions in which your child has participated. If none, please write ‘Nil’

Please circle the level that best describes your child’s general academic and scholastic progress:

Which is your child’s best subject?

Does your child have a Personalized Learning Plan or equivalent at school?

YesNo

If so, what?

When did the plan commence?

When you come to see us:

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

YesNo

If yes, please briefly state this so it can be avoided

So that we can remember you and your child, we would like to take a photograph of those who attend the initial consultation. Usually the photo is of parents/guardians and child together. This photograph is pasted into your child’s electronic file. Do we have your permission to take a photograph of you together with your child? (Please feel free to submit a photo of your choice).

YesNo

Child Minding Policy

The CDN administrative staff are not in a position to provide child care or supervise your child.

If you anticipate that your child might be required to spend time in the waiting room without you, and would require supervision during that time, then please arrange for a suitable adult to attend your consultation with you, so that they can be with your child as they wait.

If you are unsure if this applies to your circumstances then please ask your Clinician or the administration staff prior to your visit.

SECTION 4: Parent/Guardian Name and Signature

Completed by

Signature

Draw signature|Type signatureClear

Date