We would be very grateful if you could please fill out the form below with yes or no answers and very brief descriptions
Parent / Guardian Name *
Name of the Child *
Date of Birth of the Child *
Parent/Guardian Email Address *
Parent/Guardian Contact Number *
Name of School and in which Borough.
Is it a Local Authority School or a Private School?
Do you have other kids in the family?
If yes, please write the name and age of the child(s)
Is English the first language for the child?
Who is requesting this assessment?
Has your child been assessed by any other professionals like -
Speech and Language Therapist
Has your child been referred to CAMHS?
Does your child have an EHCP?
If "No" are you wanting to apply for an EHCP?
What is the main reason for seeking the assessment?
What do you hope will be achieved by this appointment?
Do you need this report for a specific reason?
If 'yes' please give details:
Are there any special family circumstances that need to be considered such as:
illness in the family
or parent separation/divorce?
If 'yes' please give brief details:
Are there members of the family or close relatives who may have reading or spelling difficulties or other learning difficulties?
Has the school flagged anything up?
If 'yes' what have they flagged?
Is any regular medication being taken?
If 'yes' does this affect your child's attention/concentration/memory in anyway?
Has your child lost any skills recently or deteriorated in any way?
If 'yes' please give details
Would you consider your child to have attention and concentration difficulties?
Would you consider your child to have emotional- behavioural difficulties at:
Was your child late in developing their language skills?
Do you have any concerns about your child's understanding or spoken language?
Did your child have any delay in gross motor skill development (crawling/walking)?
Are you concerned about (walking, balance, motor-coordination, writing, drawing, finger manipulation?
Which hand does your child use for writing?
Has your child's vision and hearing been assessed recently?
Would you consider your child to have friends at home and school
Has your child ever had extra teaching at school or home?
Does your child receive extra time, a reader for tests/exams?
Will your child be sitting a school entrance exam in the near future?
Is the school supporting your child's difficulties?
Is there anything you would like to add to this questionnaire that has not been covered which you might think is relevant to the assessment?
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