Ana Tu Psychology

Background Questionnaire for Parents/Guardians - Ana Tu Psychology

Ana Tu Psychology

Port Lincoln SA 5606
Ph: 7076 9079

Background Questionnaire for Parents/Guardians

Thank you for taking the time to complete this questionnaire. The information you provide helps us understand your child's history and needs as part of the psychoeducational assessment process.

1. Child & Referral Details

Child's Name

Date of Birth

Is your child:

Male

Female

Completed By (First Name)

Completed By (Surname)

Date

Relationship to Child

Mother

Father

Guardian

Other

School

What is your reason/s for the referral?

2. Family Background

Who lives at home with the child? (include adults' names & relationship, and names & ages of any other children)

Mother's first name

Father's first name

Mother's country of birth & cultural background (e.g. Aboriginal, Vietnamese, etc.)

Father's country of birth & cultural background

Languages spoken at home

3. Developmental History

Description of pregnancy & birth (e.g. any complications, premature, caesarean/forceps, etc.)

Please specify any major illnesses/injuries/hospitalisations

Is your child on any medications?

Yes

If yes, please specify

Please specify at what age your child independently:

Sat

Crawled

Walked

Spoke first words

Put words together

Spoke in sentences

Toilet trained - day

Toilet trained - night

7. Play & Social Skills

Please indicate your child's level of play:

By themselves

Alongside other children

Cooperatively with others

Indicates has preferred friends

How much time do they catch up with friends outside of school per week on average?

Please indicate your child's social skills:

	Yes	No	Developing
Has awareness of other children
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)

8. Interactions with Adults

Please indicate your child's interactions with adults:

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

Other/s (please specify)

10. Sleep

Does your child have any difficulties getting to sleep or staying asleep?

How many hours do they sleep per night on average?

11. School History

How long has your child attended their current school?

Please list any previous schools and for which year levels

12. Professional Involvement

Please indicate any involvement your child has had with other professionals/agencies. Please write the professional's name, agency & time period involved, and attach any relevant reports.

Speech Pathologist

Occupational Therapist

Physiotherapist

Paediatrician

Other/s (please specify)

13. Other Information

Other relevant information

Thank you for your time in completing this questionnaire.