Pre-assessment Questionnaire - Under 18's

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Parent/Carers detail's

This section will take around 1 minute to complete

Parent/Carer Name(Required)

Title First Last

Relationship to child/young person(Required)

Would you like to provide a written pronunciation of your name?

Would you like to provide a second parent/carers details?(Required)

Yes

Additional Parent/Carer Name

Title First Last

Relationship to child/young person

Would you like to provide a written pronunciation of your name?

Relationship status of parent/carers(Required)

If other please specify(Required)

Address(Required)

House Name/Number Street City/Town County Postal Code Country

Daytime Phone number(Required)

Personal email address(Required)

Child/Young person's details

This section will take around 1 minute to complete

Child/young person's details(Required)

First Last

Nickname or chosen name

Would you like to provide a written pronunciation of child/young person's name?

Date of Birth(Required)

Gender(Required)

Child/young person's preferred pronouns(Required)

If other please specify

Nationality(Required)

Ethnicity(Required)

Religion(Required)

Does you child/young person have any known diagnosis?(Required)

Yes

If yes please provide details(Required)

Does you child/young person have any suspected diagnosis?(Required)

Yes

If yes please provide details(Required)

Are you suspecting Dyslexia?(Required)

Yes

Please choose what educational setting your child/young person is attending(Required)

Nursery mainstream

Nursery specialist

Childminder

Pre-school mainstream

Pre-school specialist

School mainstream

School specialist

Not currently attending school

School Part time

School PRU

Private School

School Hospital

Home Educated

College Mainstream

College specialist

Other

What year group are they in, or what year group would they be in if they were attending a learning environment?

Why you would like support from bibic?

This section can take around 10 minutes to complete. The questions focus on the challenges your child or young person is experiencing. Your answers will help bibic recommend the most appropriate assessment and support.

Main Areas of concern(Required)

Within bibic’s assessment, we are not limited to these concerns; however, they provide a starting point for our focus and help us understand the challenges your child or young person is experiencing. Based on your choices we will ask you to provide more information around these areas.

Select between 3 and 5 choices.

Behavioural responses

Sensory processing

Social (interacting with others)

Language (Expressive and/or comprehension)

School (ability to manage in a classroom environment)

Academic (reading, writing, maths)

Memory and auditory processing

Independence

Visual

Fine Motor (handwriting, tasks with hands)

Gross motor (movement, mobility, balance and coordination)

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

Behavioural responses

Tell us about their behaviour, both positive and areas of challenge

Tell us about their emotional wellbeing

Sensory Processing

Over Sensitive

Sound

Touch

Smell

Light

Movement

Food

Under Sensitive

Sound

Touch

Smell

Light

Movement

Food

Please describe in detail the sensory challenges that your child/young person experience

Social (Interacting with others)

Tell us about their social development

Do they understand social codes of conduct?

Yes

If yes can they follow them?

Do they understand facial expressions and body language?

Language (Expressive and/or Comprehension)

How do they communicate with you and others?

Can they be literal?

Yes

For example, do they interpret language literally or understand humour, sarcasm, jokes, figures of speech and implied meanings.

If yes please provide more detail

Are they able to follow simple and complex instructions?

Any additional comments around understanding of language?

School (managing in the classroom enviroment)

How do they manage in the learning environment?

Do they receive any additional support?

Yes

If yes tell us what support they receive?

Academic (reading, writing, maths)

How do they engage with learning?

Are they able to read?

Yes

If yes do they understand what they read?

Is there anything else you would like to tell us about their learning?

Memory and Auditory Processing

Do you have any concerns regarding their memory?

Do you have any concerns regarding their hearing?

Independence

What is their self-care like?

Are they able to travel independently, if age appropriate?

Additional comments regarding life skills

Visual

Do you have any concerns regarding vision?

Fine Motor (handwriting, tasks with hands)

Can you share information regarding their fine motor skills?

Gross motor (movement, mobility, balance and coordination)

Do you have any concerns regarding their mobility?

Do they have good balance and coordination?

Have they got good spatial awareness?

Strengths

What makes them happy?

What are their interests and hobbies?

What are their strengths?

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

Pre-assessment Questionnaire – Under 18’s

Parent/Carers detail's

Child/Young person's details

Why you would like support from bibic?

Behavioural responses

Sensory Processing

Social (Interacting with others)

Language (Expressive and/or Comprehension)

School (managing in the classroom enviroment)

Academic (reading, writing, maths)

Memory and Auditory Processing

Independence

Visual

Fine Motor (handwriting, tasks with hands)

Gross motor (movement, mobility, balance and coordination)

Strengths