Over 18’s Pre-assessment questionnaire

Pre-Assessment Questionnaire – Over 18’s

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

We are currently responding to enquiries within 3 weeks of receiving the completed form.(Required)

I understand the above

Please note: bibic does not provide a diagnosis, but instead offers a holistic understanding of an individual’s strengths and challenges. If standardised tests have been completed within the past year, we may be unable to repeat them. This does not prevent us from assessing and supporting the individual’s needs; alternative methods may be used to address any challenges identified.(Required)

I understand the above

Assessment attendee details

Has the attendee and/or their partner, ever served or are currently serving in the armed forces?(Required)

Yes

Assessment attendee name(Required)

Title First Last

Would you like to provide a written pronunciation of the attendee's name?

Date of birth(Required)

DD slash MM slash YYYY

Relationship status(Required)

Gender(Required)

Your pronouns(Required)

He/His

She/Hers

They/Them

Prefer not to say

If other please specify(Required)

Nationality(Required)

If other please specify(Required)

Ethnicity(Required)

If other please specify(Required)

Religion(Required)

If other please specify(Required)

Address(Required)

House Name/Number Street Town County Post Code Country

Daytime phone number

Mobile number(Required)

Personal email address(Required)

Do you have any children?(Required)

Yes

If yes how many?(Required)

How did you hear about bibic?(Required)

If other please specify(Required)

Second Contact information

If you are completing this form on behalf of someone else, please provide your own contact details here as their second contact. If you are completing this form for yourself, please provide the contact details of a second person who can be reached if necessary, such as a family member or partner.

Second contact's name(Required)

First Last

Would you like to provide a written pronunciation?

Daytime phone number

Email address

Three main concerns(Required)

Select exactly 3 choices.

Fine motor (handwriting, tasks with hands)

Gross motor (movement, mobility, balance and coordination)

Language comprehension (understanding language)

Expressive language (communicating)

Academic (reading, writing, maths)

Work (completing tasks, workload)

Independence

Social/relationships

Sensory Processing

Memory and auditory processing

Learning environment

Emotional wellbeing

Visual

Other

If other please specify(Required)

What would you like to achieve from this assessment?(Required)

Do you have any known diagnosis?(Required)

Yes

If yes please provide more details including dates(Required)

Do you have any suspected diagnosis?(Required)

Yes

If yes please provide more details(Required)

Please provide below any tests or screenings that have been completed within the last 5 years(Required)

Health and Safety

Are you likely to display verbal aggression whilst in the centre?(Required)

Very unlikely

Somewhat unlikely

Somewhat likely

Very likely

Please specify(Required)

How likely are you to display anxiety/worry?(Required)

Very unlikely

Somewhat unlikely

Somewhat likely

Very likely

Please specify(Required)

How likely are you to use physical behaviours when you are overwhelmed?(Required)

Very unlikely

Somewhat unlikely

Somewhat likely

Very likely

Please specify(Required)

Is there a risk of harm to you?(Required)

Very unlikely

Somewhat unlikely

Somewhat likely

Very likely

Please specify(Required)

Is there a risk of harm to other people in the centre?(Required)

Very unlikely

Somewhat unlikely

Somewhat likely

Very likely

Please specify(Required)

Can you tell us about any triggers?(Required)

These are to keep everyone safe within the centre

Please tell us of any accessibility needs for anyone attending the assessment(Required)

Will you need any help accessing our centre

Does anyone attending bibic have any severe allergies?(Required)

Yes

Does anyone attending bibic carry an Epi pen?(Required)

Yes

If yes please provide more information(Required)

Vision/Auditory

Do you have any concerns regarding vision?(Required)

For example, Skipping lines when reading, getting their words muddled, aversions to bright lights, sight loss, wears glasses

Do you have any concerns regarding hearing?(Required)

For example, mishearing things, misunderstanding, hearing loss, hearing aids.

Speech and language – Expression

How do you best communicate with others?(Required)

Signs and pictures, Makaton, non-verbal, pre-verbal, verbal, how do you communicate in different settings, are you echolalic, do you use texting to communicate?

Speech and language – Understanding

Can you be literal?(Required)

Yes

If yes please provide more details(Required)

Do you understand time concepts?(Required)

Are you able to follow simple and complex instructions?(Required)

Any additional comments around understanding of language(Required)

For example, tone of voice, understanding the subtleties of language

Gross motor skills (big movements)

Do you have any concerns regarding mobility?(Required)

For example, sitting, using aids, hypermobile, muscle tone

Do you have good balance and coordination?(Required)

Have you got good spatial awareness?(Required)

Fine motor (hand and finger control)

Can you share information regarding your fine motor skills?(Required)

For example, hand writing, picking up items, dexterity, pen/pencil grip

Sensory Processing

Can you be sensitive to sound?(Required)

Can you be sensitive to touch?(Required)

Can you be sensitive to smells?(Required)

Can you be sensitive to light?(Required)

Do you seek or avoid movement?(Required)

Can you share information regarding your eating habits?(Required)

Any additional information regarding sensory processing(Required)

Learning/Work Environment

Please select your work/learning environment(Required)

College Mainstream

College specialist

University

Employed

Unemployed

Self-employed

Looking for work

Other

If other please specify(Required)

How do you manage in this setting?(Required)

How do you engage with learning/work?(Required)

Concentrating, engagement, change in focus, planning, organising, independence

Are you suspecting Dyslexia?

Yes

Do you receive any additional support?(Required)

Yes

If yes please tell us what support you receive(Required)

Any other information(Required)

Daily living tasks and life skills

Tell us about your sleep(Required)

Tell us about your self-care routines(Required)

Eating, dressing, personal hygiene

How is your understanding and management of money?(Required)

Are you able to travel independently?(Required)

Driving, public transport, planning journeys

Additional comments regarding life skills(Required)

Making appointments, organisation

Behavioural responses

Tell us about your behavioural responses, both positive and areas of challenge(Required)

Triggers, meltdowns, burnout, withdrawal, easily influenced, new skills learnt, adaptable

Tell us about your emotional wellbeing(Required)

Anxiety, self-esteem

Social development

Tell us about your social skills(Required)

Friendships, relationships, interaction with others, safety awareness

Do you understand social codes of conduct?(Required)

Yes

If yes can you follow them?(Required)

Do you understand facial expressions and body language?(Required)

What makes you happy?(Required)

What are your interests and hobbies?(Required)

What are your strengths?(Required)

Communication, humour, kindness, empathy, logical, organisation, problem solving

Is there any additional information you would like to share with us?(Required)