Psychology Service Child Initial Questionnaire

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*

First Last

Date of Birth*

Child's Age*

Gender*

Male

Female

Prefer not to answer

Name of School*

Grade*

Languages Spoken*

If more than one, please indicate your child’s primary language with an asterisk*

Nationality*

Form completed by*

First Last

Relationship to child*

How did you hear about us?*

Father's Name*

First Last

Father's Profession*

Phone*

Email*

Mother's Name*

First Last

Mother's Profession*

Phone*

Email*

People living at home and their relationships to child

(siblings, helper, others? names and ages)

2. Developmental History

Pregnancy Length

weeks

Weight at Birth

kgs

Birth Procedure

Any complications for child and/or mother?

Yes

If yes, please describe

At what age did the following occur?

Crawl

Walk

First Sounds

First Words

Day-time toilet training

Night-time toilet training

How are the child’s motor skills? (tying shoelaces, catching a ball, use of scissors, balance, running etc)

Did the child ever see other professionals? Psychologist, speech and language therapist, Occupational therapist, psychiatrist, neurologist? (Please provide Names and details)

Was the child ever involved in an accident, had surgeries or was hospitalised, is taking medication, Asthma, epilepsy, fits or convulsions, head injury, or any other diagnosis in the past? (Please provide details)

3. Educational History

Did the child's teacher raise concerns?*

Yes

Are there any learning difficulties?*

Yes

If yes, please provide details:

What is the child's relationship like with teachers?

What is the child's relationship like with peers?

Is there any educational support in place for the child?

Parent's Observations

What are your actual concerns: since when? (e.g. Behavioural Problems, Anxiety, Mood, Self-esteem, Motivation Learning, others, please detail)

How else did you try to address these?

Which aspect(s) of daily living are being affected?

At what level are you concerned for your child’s well-being?

Minimal Concern (Curiosity about child's behaviour)

Concerned (some changes in behaviour)

Worried (unexplained changes in behaviour)

Very Worried (unable to help child)

What do you hope would improve after seeing a psychologist?

What changes would you like to see in your child?

What are his/her strengths?

Does your child's mood change a lot depending on context? (e.g. Home, School, Time of Day, Day of Week)*

Yes

If yes, please provide details:

Has your child witnessed any traumatic events? And when? (e.g. Car Collision, Robbery, Death of Family Member)

Has your child experienced any major stresses? And when? (e.g. Divorce of Parents, Family Illness, International Relocation, Bullying, Death of a Close Friend / Family Member)

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:

Father

First Last

Phone

Father Signature

Mother

First Last

Phone

Mother Signature

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

1. General Information

2. Developmental History

3. Educational History

Parent's Observations

5. Consent

Name of Parents/Legal Guardian:

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