Psychology Intake Form

The following questionnaire is designed to assist with gathering information to

understand your child’s unique circumstances and guide treatment.

---

Child's Full Name *

Date of Birth *

Age

GenderMaleFemaleOther

Person completing questionnaire *

Relationship to childMotherFatherParentCarerGuardianFoster ParentStep Parent (Mother's partner)Step Parent (Father's partner)

Today's Date *

Family members and household composition

Name

Relationship to child

Age

Custody arrangements if applicable

Are there any legal proceedings currently occurring

YesNo

If so please provide details

Briefly describe the concerns you have about your child or family situation

When was the problem first noticed

Please describe your child’s strengths

Please list your child's favourite activities

Please list your child's least favourite activities

Developmental History

Were there any problems during pregnancy? If yes, please describe

Was the birth mother taking any medications during pregnancy? 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 child 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 child was able to do the following:

Showed response to parent

Rolled over

Crawled

Sat alone

Babbled

Spoke first words

Said several words together

Dressed self

Toilet trained

Fed self

Rode Bicycle

---

Social and Emotional Development

Please tick if you currently observe any of the following:

Difficulty communicatingPrefers to play aloneDoes not get along well with peersDoes not get along well with siblingsIs aggressiveIs shy or timidIs more interested in objects than peopleEngages in dangerous behavioursHas particular fearsSoils self or bedFrequent tantrumsFrequent nightmaresDifficulties sleepingEats poorlyFrequently in troubleAvoids things that cause anxietyIntense interestsFixated on gaming or technologyPoor behaviour if gaming not availableAvoids/Refuses school

Education

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

Day care

Kindergarten

Primary school

High school

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

Has your child been given any additional supports at school?

YesNo

If yes, please provide details:

Is your child achieving at the expected level or above on their most recent school report?

YesNo

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

Medical History

Does your child have any current medical conditions?

YesNo

If yes, please provide details:

Does your child take any medications?

YesNo

If yes, please list medications and reasons:

Has your child previously experienced any serious illnesses or injury?

YesNo

If yes, please provide details:

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

YesNo

If yes, please provide details:

---

Treatment History

Has your child previously consulted a professional for psychological or behavioural problems?

YesNo

If yes, please provide details:

Has your child previously or currently accessing other allied health treatments Eg. Speech pathology, occupational therapy?

YesNo

If yes, please provide details:

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

Parenting and Behaviour Management

What disciplinary measures do you use when your child misbehaves? Please tick all applicable.

Ignore problem behaviourScold childThreaten childWithdraw access to technologyRedirectionTime outSend child to their roomRemove an item such as a toyReason with childOther

Other (Please describe)

What measures do you use to reward desired behaviour? Please tick all applicable.

PraiseReward charts with goalAccess to technologyMoneyRewards (e.g. sticker)AffectionFood based rewards (e.g. lolly)Other

Other (Please describe)

Technology

Please list any devices such as mobile phones, iPads or gaming consoles your child has access to:

How many days per week does your child have access to devices or gaming?

How many hours per day does your child average playing on devices or gaming?

Do you experience any problems if restrictions are placed on access to devices or gaming? If yes, please provide details:

Do you consider that access to devices or gaming causes problems for your child or family? If yes, please provide details:

---

If there anything else relevant to your child of family circumstances that I should be made aware of?

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.

Thank you for your time.

Please wait, files are uploading..

Submit