Client’s full name

D.O.B.: / /

Country of Birth:

Male

Female

Form completed by: ____________________________ Date completed: ___________________________ Clientôs Parent/Carer Details Marital Status of Parents (if applicable):

Parent/caregiver Name: Parent/caregiver Name:

Address: Address (if different):

P/C: P/C:

Home Phone: Home Phone:

Work Phone: Work Phone:

Mobile Phone: Mobile Phone:

Email Address: Email Address:

Are the above mentioned the legal guardians of this child? Parent/caregiver 1: Yes No Parent/caregiver 2: Yes No If no has been indicated, please comment on the degree of contact with biological parents, and whether any court orders exist to govern these arrangements:

Preschool / School Details

Name of preschool/school attending (if applicable): Yr:

Address:

P/C:

Contact person: Phone:

Email address: Fax:

Does the child receive assistance from a support person? Yes No Has the child ever repeated a grade? Yes No If yes, which grade? __________________

Referral Details

Referred by: Parent Self GP Paediatrician Psychologist Other: _______________________

(Please attach/fax copy of referral if applicable (including Mental Health Treatment Plan)

Name of Referrer (if other than Parent/Self):

Address:

P/C:

Reason for Referral: How did you FIRST hear about our psychology services?

Parent/Carer Background Information Questionnaire Name of Client: _________________________________________________________________________ The following questions will provide Hopscotch and Harmony preliminary information about your child. Please answer these questions with as much detail as possible. Leave blank any question you would rather not answer.

Physiological Background Was the pregnancy normal?

Yes No Don’t know

If “no”, please provide details: _____________________________________________________________________ Was the child birth normal?

Yes No Don’t know

If “no”, please provide details of complications _________________________________________________________ Did the child meet his/her developmental milestones? (e.g. crawling, walking, speaking?)

Yes No Don’t know

If “no”, please provide details _________________________________________________________ Any serious childhood illnesses or medical conditions?

Yes

No

If “yes”, please provide details: _____________________________________________________________________ Is the child receiving any medication? Yes

No

If “yes”, please provide details: _____________________________________________________________________ Does the child have any allergies? Yes

No

If “yes”, please provide details: _____________________________________________________________________ Any serious injuries (particularly head injury)?

Yes

No

If “yes”, please provide details: _____________________________________________________________________ Any hospitalisation?

Yes

No

If “yes”, please provide details: _____________________________________________________________________

Siblings (names and ages):________________________________________________________________________ Please indicate any special needs or concerns regarding the other children living in your home: Who are all the people who live in the child’s home? _________________________________________________

Psychological Background

Select if you are concerned about the following areas:

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Fears and anxiety _____________________________________________________ Shyness or social withdrawal ____________________________________________ Anger_______________________________________________________________ Frustration___________________________________________________________ Depression___________________________________________________________ Tantrums____________________________________________________________ Sleep difficulties (e.g., recurring nightmares)_________________________________ Bed wetting___________________________________________________________ Other: _______________________________________________________________

Has the child ever been diagnosed with a psychological disorder?

Yes

No

If “yes”, please provide details:_____________________________________________________________________________

Family Background Select if the child has been exposed to any of the following

Select if there is a history in the child’s immediate or in the mother’s or father’s extended family Who?

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Divorce/separation

Marital discomfort

Family violence

Death of a parent

Death of a relative/friend

Unemployment

Substance use in the family

Serious illness in the family

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Autism Spectrum Disorders

Learning Problem/Disabilities

ADHD– Attention Problems

Depression OR Bipolar Disorder

Behavior Problems in School

Anxiety Disorders (OCD, Phobias)

Intellectual Disability

Psychosis/Schizophrenia Substance

Abuse/Dependence

Other family issues: ____________________________________________

Other mental health concerns: _________________________________________________

Educational Background Did the child go to pre-school?

Yes No

If “yes”, any difficulties?

Yes No

If “yes”, please provide details of difficulties:

Select the child’s CURRENT educational performance:

Very poor Poor Average Good Very Good

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Describe the general feedback from teachers:

What areas of school work does the child find easy and fun?

What areas of school work does the child find difficult and boring?

Does your child experience and behaviour or social problems while in school? If so, please explain:

Does the child participate in extra curricular activities?

Yes No

If “yes”, please list all activities and the time involved: 1..………………………………………….. 2..………………………………………….. 3 ..………………………………………….. 4 ..………………………………………….. 5. …………………………………………..

Hours per week: ……………………………. Hours per week: ……………………………. Hours per week: ……………………………. Hours per week: ……………………………. Hours per week: …………………………….

Please list names of previous schools attended: ___________________________________________________Years attended: ________________________ ___________________________________________________Years attended: ________________________

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Describe your concerns or the reason for seeking support:

Overall, how concerned (worried) are you about your child?

Not at all A little Moderately Quite a lot Extremely Mother Father □

What do you find most challenging about raising your child? What (if any) things would you like to work on as an individual/couple? What are your child’s interests? Favourite toys? Favourite activities? Describe the best things about your child – what are his or her particular strengths?

Is there anything other information you feel is important for understanding you and your child?

Thank you for completing this form

Please save this file to your computer and attach it to an email to admin@hopscotchandharmony.com.au

This will allow your psychologist to read the information prior to your appointment. Otherwise please print and bring to your first appointment If your child is being assessed for Autism Spectrum Disorder please complete the following two pages

Which of the following best describes your child’s current speech/language abilities (please indicate)

Non verbal or uses single words only

Uses short phrases, e.g. “I want drink”, “Daddy go car”, “Mummy come here”

Uses fluent speech, e.g. “I went to the shop and bought a lolly”, “Last week I got an award for spelling”.

1. Does your child regularly repeat words, phrases or sentences exactly as he/she has heard in the past, in an unusual way?

2. For children with fluent speech only - is it easy to have a conversation with your child?

3. Does your child look at people when talking/listening to them?

4. Does your child show interest in other children, e.g. watching them, talking to you about them, playing with them?

5. Does your child prefer to play on their his/her own rather than with others?

6. Does your child ever approach other people inappropriately?

7. Does your child seem aware of or interested in the feelings of others?

8. Does your child spontaneously offer comfort to others if they are hurt, ill or distressed?

9. Does your child have any special routines or things that he/she likes to do in a particular way or order? 10. How does your child cope if his/her activities are interrupted?

11. Has your child become preoccupied or obsessive about a particular object/subject or activity?

12. Does your child regularly display any unusual physical mannerisms or repetitive body movements, e.g. hand flapping or flicking, toe walking, spinning?

13. Does your child have any unusual sensory interests or sensitivities, e.g. sniffing books, over-sensitive to particular noises or to touch?

14. What particularly motivates your child (i.e. praise, cuddles/tickles, particular foods or access to favourite toys or activities)?