Parent - Child Assessment Questionnaire | Forms | Headstart Intervention Services

Child's Name (First name & Surname)

Parent(s) / Caregiver(s) Name(s)

Name of Parent/Caregiver completing this form

Who does the child live with?

Referred to Headstart by

Primary Language spoken at home

Any additional languages spoken at home?

What are the names and ages of your child's siblings?

Please describe the concerns you have about your child

Please describe what you are hoping to obtain from visiting Headstart

Is there any family history (both paternal and maternal extended families) of the following?
(if yes, please specify relationship, eg. maternal uncle, paternal niece)

Autism Spectrum Disorder (Yes/No)

Learning Disorders (Yes/No)

Communication / Hearing Disorders (Yes/No)

Mental Health Issues / Illness (Yes/No)

(eg depression, anxiety, bi-polar, alcohol / drug abuse)

Describe your pregnancy and birth

Please include the following: Health/Complications,Life events/major stressors, Post-natal depression, Birthweight, Pre-term/Fullterm, Delivery.

How would you have described your baby

(e.g., feeding, sleeping, medical conditions, temperament/personality) (0-12 months)

Language
Age (in months) when your child (if you cannot remember, please indicate whether it was delayed or as expected/typical)

Spoke first word/s (What were they)?

Combined 2-3 words?

Spoke in sentences?

Motor
Age (in months) when your child (if you cannot remember, please indicate whether it was delayed or as expected/typical)

Crawled?

Walked?

Fed self?

Toilet trained?

Is your child left or right handed?

Left

Right

Does your child have any difficulty with any of the following?

Swallowing

Chewing

Drinking

Blowing

Drooling

Has your child had any of the following

If you answered yes to any above, please indicate at what age, for each

Has your child's hearing been tested? (Yes/No) If Yes, please include results.

Has your child's vision been tested? (Yes/No) If Yes, please include results.

Has your child had any of the following health concerns (if yes, please describe)?

Ear aches / Ear infections? (Yes/No)

Allergies (including food)? (Yes/No)

Any other serious or recurrent illnesses? (Yes/No)

Any operations? (Yes/No)

Any accidents? (Yes/No)

Any medications (past and current)? (Yes/No)

Dental problems? (Yes/No)

Other Medical History? (Yes/No)

Has your child previously engaged in other therapies (if yes, please list and describe)?

Is your child currently partaking in any therapies (if yes, please list and describe)?

Are there relevant assessments of which we should be aware?

Paediatric Report

Speech Pathology Reports

Psychology Reports

Occupational Therapy Reports

(if yes, please bring to the appointment)

Other, please specify

Has your child attended Childcare, Occasional Care or Kindergarten?

If so, please describe their participation (e.g. have staff noted any concerns? How do they play with other children? Do they join in at group time? How is their overall behaviour? Have any unusual behaviours been observed?)

Name of Childcare/Occasional Care/Kindergarten

Name of Director/Teacher

Does your child attend school?

Describe their participation (e.g. have teachers ever noted concerns, friendships, academic level, behaviour in the classroom, behaviour in the school yard)

Name of School

Name of Teacher

Year level

Please outline and briefly describe any significant life events in your child's life

(e.g. domestic violence, abuse/neglect, divorce/separation, house fire, floods, car accidents etc.)

Are there any issues you do not want discussed in front of your child (if yes, please note briefly)?