Psychology Service Child Initial Questionnaire

"*" indicates required fields

This questionnaire will take approximately 10 minutes to complete. The information you will provide will help our psychologist understand your child’s difficulties better. Following this, our office will email you to book an appointment. Thank you!

1. General Information

Child's Name*
DD slash MM slash YYYY
If more than one, please indicate your child’s primary language with an asterisk*
Form completed by*
Father's Name*
Mother's Name*
(siblings, helper, others? names and ages)

2. Developmental History

Any complications for child and/or mother?
At what age did the following occur?

3. Educational History

Did the child's teacher raise concerns?*
Are there any learning difficulties?*

Parent's Observations

Which aspect(s) of daily living are being affected?
At what level are you concerned for your child’s well-being?
Does your child's mood change a lot depending on context? (e.g. Home, School, Time of Day, Day of Week)*
Comments: Please elaborate in detail for each "Yes" answer above.

5. Consent

If my child attends sessions at IMC Psychology Service, I will consent to the following: - My child will receive individual psychological therapy at IMC. - I am aware that the contents of therapy are confidential. - I understand that feedbacks entailing details of therapy will only be provided to parents following consent from the child. Confidentiality can/will only be breached under the following conditions: 1. Client reports that s/he is or will hurt himself or herself, and/or others. 2. If alleged child abuse or neglect is disclosed. 3. If there is a legal case involving the child (not related to divorce procedures or custody and access matters) and the psychologist has been contacted by law officials. In case of Custody and Access disputes: I understand that the discussion or contents of therapy cannot be used for legal purposes related to divorce discords and/or Custody and Access matters. Rather, if psychological input is required for any legal proceedings, the psychologist will refer our family to a professional who is specialised in Medico-legal assessments and comprehensive reports for court proceedings. The first session and following therapy sessions will only be taking place upon the psychologist receiving written consent for therapy from BOTH parents. By signing this form, we agree and understand the terms explained above:

Name of Parents/Legal Guardian:

This field is for validation purposes and should be left unchanged.

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