Ana Tu Psychology

Background Questionnaire for School Staff - Ana Tu Psychology

Ana Tu Psychology

Port Lincoln SA 5606
Ph: 7076 9079

Background Questionnaire for School Staff

Thank you for taking the time to complete this questionnaire. The information you provide helps us understand the student's needs and functioning at school as part of the psychoeducational assessment process.

1. Student & Referral Details

Student's Name

Date of Birth

Is the student:

Male

Female

Completed By (Name)

Date

School

What is your reason/s for the referral?

How long have you known this student?

2. Identified Conditions

Does the student have an identified:

Speech or language difficulty

Sensory processing difficulty

Motor or motor planning difficulty

Difficulty with literacy skills

Learning disability

Difficulty with numeracy skills

Sensory impairment (hearing/vision)

Syndrome, disorder, medical or neurological condition

If yes, please describe

5. Areas of Learning

Please indicate your level of concern about the student's progress in the following:

	No Concern	Small Concern	Moderate Concern	Significant Concern
English: Speaking & Listening
Reading
Writing
Health & Physical Education
Languages Other Than English
Mathematics: Processes
Mathematics: Concepts
Science
Studies of Society & Environment
Technology
The Arts

Comments (please attach samples if significant concern)

6. Play & Social Skills

Please indicate the student's level of play:

Solitary

Parallel

Cooperative

Has a select group of friends

Please indicate the student's social skills:

	Yes	No	Developing
Has awareness of peers
Gives appropriate eye contact
Greets and uses other children's names
Able to enter other children's play
Able to interpret the actions & needs of peers at play
Can share, wait, take turns, cooperative & is considerate of others
Uses language to express feelings/emotions/wants/needs/rights
Has effective conflict resolution skills & able to manage anger/rejection

Other/s (please specify)

7. Interactions with Staff

Please indicate the student's interactions with staff:

	Yes	No	Developing
Initiates and/or contributes to conversations with staff
Complies with staff's requests/directives
Participates in and/or enjoys 1:1 interactions with staff
Requests assistance from staff as required

Other/s (please specify)

10. About the Student

Describe the student as a person (e.g. friendly, cheerful, optimistic, impulsive, anxious, etc.)

Describe the student's attitude to school work and typical work habits (e.g. ability to maintain concentration, perseverance in the face of difficulty, completion of set tasks, etc.)

11. Interventions

What actions/interventions or learning strategies (if any) are you currently implementing for this student? What works? What does not work?

12. Other Information

Please list any other relevant information

Thank you for your time in completing this questionnaire.