Teacher Questionnaire

Thank you for taking the time to complete these questions. This young person has been referred for a specialist opinion of their developmental/behavioural problems. Your contribution is very important, and we appreciate that your time is valuable.

In addition to providing information about this young person's progress at your centre, the questions provide the opportunity for you to identify any concerns you may have and indicate where consultation with health professionals may assist your work.

This form will be submitted to the Child Development Network upon completion.

Young Person's Name *

Date of Birth

Date of CDN Appointment

Teacher's Name

Your Position at the school

How long have you known this young person?

Class/Grade

Today's Date

Your School

School/Organisation Name

Educational Sector

StateCatholicIndependentHome School/Other

School Address

Street address

City

State

Postcode

School Principal/Director

School Guidance Officer

What is your role with this young person?

Where do you see their strengths/abilities/interests?

What concerns, if any, do you have for this young person? Are there any areas where we may be able to assist the school?

What does this young person do well, what are their interests, and what do they enjoy?

What is your level of concern overall about this child?

NoneMildModerateHigh

Please elaborate on these, or any additional concerns you have about this young person.

How might our services (CDN) potentially help you with this young person?

Is this young person receiving needs support at your centre/school? If so, please describe:

What is the young person's current educational setting (size/type of classroom)?

Any additional comments/questions?

Please provide this young person's parents with copies of any assessment report, or any other written information that may be of assistance.

If you wish, you can contact us directly at cdn@cd.net.au or on (07) 3369 3369.

Thank you.