Child Form

General Information

Child's Name

First Name

Last Name

Age and Date of Birth

Name of School and School Year

School attendence has been:

Excellent

Good

Concerning

What strengths, interests and activities does your child like?

Are there any activities they avoids, actively dislikes or is known to struggle with?

Reasons for referral

Please provide details around your concerns and current issues. (e.g. learning; behaviour; social; communication; etc)

Parental Information

Please provide both parents names, contact details, occupations and addresses.

Parent's Names [both please] / Guardian's Names

First Name

Last Name

Occupation(s)

Phone Number(s)

Email Address(s)

Postal Addresses

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Languages

Which languages are spoken at home?

Primary language your child uses to speak to you?

Health & History

Year of last vision and hearing tests

Were there any concerns with hearing or vision?

Any significant injuries or health issues?

Any formal medical/physical/sensory diagnoses?

example: diabetes, hearing aids...

Any formal psychological diagnoses?

example: anxiety

Any recent significant family events?

example: migrated to New Zealand : parents recently separated

Has your child had a previous assessment?

Yes - ( If yes, please email the office a copy of the report )

Administrative

How did you hear about us?

Consent

It is a legal requirement that both parents agree to their child's assessment ahead of it commencing [unless deceased].

I understand that in order to move forward with an assessment of a minor, that the consent of both parents is legally required.

If a report is required, which way(s) would you like to receive the report?

Hard Copy

Booking an appointment/assessment, please tell us if there is a preference for the psychologist or the day, dates & times - thank you.