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Pre-Assessment Questionnaire
Make an enquiry.
Step
1
of
15
6%
Your details
Name
(Required)
Dr.
Miss
Mr.
Mrs.
Ms.
Mx.
Prof.
Rev.
Title
First
Last
Parent/carer preferred pronouns
(Required)
He/His
She/Her
They/Them
Prefer not to say
Name
Dr.
Miss
Mr.
Mrs.
Ms.
Mx.
Prof.
Rev.
Title
First
Last
Parent/carer preferred pronouns
He/His
She/Her
They/Them
Prefer not to say
Marital status of parents
(Required)
Married
Single
Divorced
Civil Partnership
Separated
Other
If other, please specify
Step parent/s name if applicable
Dr.
Miss
Mr.
Mrs.
Ms.
Mx.
Prof.
Rev.
Title
First
Surname
Address
(Required)
House name or number
Street name
Town
County
Postal Code
Phone
(Required)
Mobile
Email
(Required)
Occupation
Does the child/young person have any siblings
(Required)
Yes
No
Siblings, name, age and any known diagnoses
(Required)
Child/ Yound person's details
Name
(Required)
First
Last
Child's preferred pronouns
(Required)
He/His
She/Her
They/Them
Prefer not to say
D.O.B
(Required)
MM slash DD slash YYYY
Gender
(Required)
Male
Female
Non-Binary
Prefer not to say
Three main concerns
(Required)
Fine motor (handwriting, tasks with hands)
Gross motor (movement, mobility, balance & coordination)
Language comprehension (understanding language)
Expressive language (communicating)
Academic (reading, writing, maths)
Independence
Social (Interacting with others)
Sensory processing
Memory & auditory processing
Visual processing
Behaviour
School (ability to manage in a classroom environment)
Other
Does the child/young person have a known diagnosis?
(Required)
Yes
No
Please provide details of diagnosis and date confirmed
(Required)
Does the child/young person have any suspected Diagnoses?
Ethnicity
(Required)
White: English
White: Welsh
White: Scottish
White: Northern Irish
White: Irish
White: Gypsy or Irish Traveller
Any other white background
White and Black Caribbean
White and Black African
Asian: Indian
Asian: Pakistani
Asian: Bangladeshi
Asian: Chinese
Black: African
Black: African American
Black: Caribbean
Arab
Hispanic
Latino
Native American
Pacific Islander
Other ethnic group
Not known
Prefer not to say
Religion
(Required)
8th Day Adventist
African traditional & diasporic
Agnostic
Atheist
Baptist
Brethren
Buddhism
C of E
Catholicism
Chinese traditional religion
Christianity
Church of Scotland
Church of the Latter Day Saints
Eckankar
Evangelical Christianity
Greek Orthodox
Hinduism
Islam
Jainism
Judaism
Other
How did you first hear about bibic?
(Required)
Facebook/ Facebook support group
Instagram
Twitter
Through a friend
Website
Health professional
Advertising/ Television/ Radio
School
Event
Other
Do you/child/young person/family have any professionals involved?
(Required)
Yes
No
Please provide names of professionals and their involvement (how long have they worked with you/child/young person/family?)
Does the child/young person have any health conditions or allergies
(Required)
Yes
No
Please list any health conditions or allergies and please list any medications
Does the child/young person take any medications?
Yes
No
Please list any medications
Were there any complications before, during or after pregnancy?
(Required)
Yes
No
Including premature birth, low birth weight, assisted birth?
Was the child/young person born prematurely?
Yes
No
Did the child/young person have a low birth weight?
Yes
No
Were ventouse or forceps used?
Ventouse
Forceps
Neither
Was the child/young person sent to NICU or kept in hospital?
Yes
No
Did the child/young person inhale any meconium?
Yes
No
Was the birth Natural or Caesarean?
Natural
Caesarean
Was the caesarean planned or emergency?
Planned
Emergency
Were there any difficulties with breast or bottle feeding?
(Required)
Yes
No
If other, please specify
What would you like to achieve from this assessment?
(Required)
Visual and Auditory skills
Has the child/young person had an eye test?
(Required)
Yes
No
Date of eye test
DD slash MM slash YYYY
Does the child/young person wear glasses?
(Required)
Yes
No
Has the child/young person had a hearing test?
(Required)
Yes
No
Date of hearing test
DD slash MM slash YYYY
Is the child/young person five years or younger chronologically or developmentally?
(Required)
Yes
No
Does the child/young person show recognition to familiar people or toys?
Yes
No
Does the child/young person react to visual stimuli?
Yes
No
Does the child/young person react to auditory stimuli?
Yes
No
Does the child/young person mishear things?
Yes
No
Does the child/young person use strategies to manage noise levels (humming, covering ears, ear defenders)
Yes
No
Is the child/young person sensitive to light
(Required)
Yes
No
Does the child/young person struggle with reading due to visual disturbances?
(Required)
Yes
No
Any additional comments around vision and hearing
Speech and Language
Is the child/young person verbal or non-verbal?
(Required)
Verbal
Non-verbal
How does the child/young person communicate? (PECS, Makaton, Signs, Symbols)
Does the child/young person make vocalisations?
Yes
No
What noises does the child/young person make and what is the difference in them?
Can the child/young person communicate to get their needs met?
Supported
Unsupported
Does the child/young person's difficulties with speech and language cause frustration?
Yes
No
Can the child/young person express their needs?
Yes
No
Can the child/young person express their emotional needs?
Yes
No
Can the child/young person hold a conversation?
Yes
No
Does the child/young person use alternative forms of communication such as texting?
Yes
No
Any additional comments around speech and language
Comprehension
Does the child/young person respond to others communicating with them?
(Required)
Yes
No
Can the child/young person be literal?
Yes
No
Does the child/young person understand time concepts?
Yes
No
Can the child/young person follow simple instructions?
Yes
No
Can the child/young person follow a set of instructions that are more complex?
Yes
No
Does the child/young person understand what they read?
Yes
No
Does the child/young person understand social codes of conduct?
Yes
No
Does the child/young person understand the nuances of language?
Yes
No
Is the child/young person affected by tone of voice?
Yes
No
Does the child/young person understand facial expressions and body language?
Yes
No
Does the child/young person look at the person talking to them?
Yes
No
Does the child/young person respond to their name being said?
Yes
No
Can the child/young person follow key instructions such as sit or stop?
Yes
No
Does talking to the child/young person soothe them?
Yes
No
Any additional comments around comprehension
Gross Motor Skills (big movements)
Is the child/young person mobile (independently)?
(Required)
Yes
No
Did the child/young person crawl?
Yes
No
Date first crawled
DD slash MM slash YYYY
Did the child/young person commando crawl or bum shuffle?
Commando crawl
Bum shuffle
Neither
When did your child/young person first learn to walk?
DD slash MM slash YYYY
Does the child/young person have good balance and coordination?
Yes
No
Does the child/young person have good spatial awareness?
Yes
No
Can the child/young person swim?
Aided
Unaided
Can the child/young person ride a bike?
Yes
Yes with stabilisers
No
Can the child/young person throw, catch and kick a ball?
Throw
Catch
Kick
None of the above
Please select all that are relevant
Does the child/young person have good head control?
Yes
No
Can the child/young person sit?
Aided
Unaided
When provided with opportunities for free movement, how does the child/young person lie, roll or wiggle?
What is the child/young person's preferred style of lying?
Front
Back
When lying on the floor does the child/young person's head stay in midline, lean to the right or lean to the left?
Lean to the left
Lean to the right
Stays in the midline
Does the child/young person partake in any physical therapies?
Rebound therapy
Horse riding
Swimming
See's a physio
No physical therapy
Any additional comments around gross motor skills
Fine Motor
Is the child/young person mark making or writing?
(Required)
Yes
No
Is the child/young person left or right handed?
Left
Right
They use both
Does the child/young person have an effective pencil grip?
Yes
No
What is the quality of the child/young persons writing?
Good
Poor
Please indicate what cutlery the child/young person can use skilfully
Knife
Fork
Spoon
Select All
Can the child/young person manage fastenings such as buttons, laces and zips?
Buttons
Laces
Zips
All of the above
Can the child/young person dress and undress themselves independently?
Yes
No
Can the child/young person brush their teeth independently?
Yes
No
Can the child/young person brush their hair independently?
Yes
No
Does the child/young person need reminding to do self-care tasks?
Yes
No
Can the child/young person reach and grab items?
Yes
No
Can the child/young person point at objects or people?
Yes
No
Does the child/young person explore their surroundings with their hands?
Yes
No
Are the child/young person's hands open or closed?
Open
Closed
Can the child/young person feed themselves?
Finger food
Spoon/fork
Is the child/young person peg fed?
Yes
No
Can the child/young person hold a bottle or cup?
Yes
No
Does the child/young person attempt to help when dressing or undressing?
Yes
No
Any additional comments around fine motor
Sensory Processing
Does the child/young person have sensory processing difficulties?
(Required)
Yes
No
How does the child/young person react to noise, loud noise, sudden noise or busy environments?
Is the child/young person sensitive to touch and do they avoid certain textures or fabrics?
Yes
No
Does the child/young person seek tactile input such as messy play?
Yes
No
Is the child/young person a fussy eater?
Yes
No
Does the child/young person only eat certain tastes?
Yes
No
Does the child/young person only eat certain textures?
Yes
No
Does the child/young person separate their foods?
Yes
No
Does the child/young person reject foods typically eaten by children?
Yes
No
Is the child/young person constantly moving or fidgeting?
Yes
No
Does the child/young person hand flap, chew fingers or lips, pace or bounce?
Yes
No
Is the child/young person over sensitive to smells?
Yes
No
Does the child/young person prefer low lighting?
Yes
No
Any additional comments around sensory processing
Learning development
Please tick what setting the child/young person attends
(Required)
Nursery
Childminder
Preschool
Specialist nursery/preschool
School
Special school
College
University
Home educated
SEMH School
Pupil referral unity
Employed
Other
If other please specify
How does the child/young person manage in this setting, including their behaviour?
(Required)
How does the child/young person manage with learning or working?
(Required)
Does the child/young person receive any additional support?
(Required)
Yes
No
Please provide us with what support the child/young person receives such as one to one support, educational psychologist, additional tutoring etc.
Does the child/young person have difficulties concentrating or engaging?
(Required)
Yes
No
Does the child/young person struggle to change task or change their focus?
(Required)
Yes
No
Does the child/young person have difficulties with planning, organising and independence?
(Required)
Yes
No
N/A (too young)
Does the child/young person manage toileting independently?
(Required)
Yes
No
Is the child/young person over the age of 16 years?
(Required)
Yes
No
Can the young person manage to organise their daily lives?
Yes
No
Can the young person plan/manage their time effectively?
Yes
No
Can the young person manage their own finances?
Yes
No
Can the young person organise their own appointments?
Yes
No
Any additional comments around learning, working, development and independence
Social development
Which age bracket does the child/young person fall in?
(Required)
0 – 5 years
5 – 13 years
14 years and older
Does the child show interest in others?
Yes
No
How does the child interact with others?
Is the child happy to explore their environment independently?
Yes
No
Does the child respond well to routine?
Yes
No
Does the child have an awareness of cause and effect?
Yes
No
Is the child's play repetitive?
Yes
No
Does the child have a favourite toy or activity?
Yes
No
What is the child's favourite toy or activity?
What makes the child happy?
Does the child/young person engage in imaginative play?
Yes
No
Is the child/young persons play mimicked from things they have seen or watched?
Yes
No
Does the child/young person prefer to play independently or in a group?
Independently
In a group
Does the child/young person have good safety awareness?
Yes
No
Does the child/young person have good stranger danger awareness?
Yes
No
What makes the child/young person happy?
What are the child/young persons interests and hobbies?
What are the child/young persons strengths?
Does the young person have a group of friends?
Yes
No
Does the young person socialise regularly?
Yes
No
Can the young person plan social events?
Yes
No
Are the young person's friends the same age?
Same age
Older
Younger
Are the young person's friends mostly online?
Yes
No
Does the young person have good safety awareness?
Yes
No
Does the young person have good stranger danger awareness?
Yes
No
What are the young persons interests and hobbies?
What makes the young person happy?
What are the young persons strengths?
Any additional comments around social development
Behaviour
Is the child/young person developmentally or chronologically 5 years or younger?
(Required)
Yes
No
Does the child/young person have good or poor sleeping patterns?
Good
Poor
What does the child/young persons sleeping patterns look like?
Does the child/young person sleep in their own bed?
Yes
No
How does the child/young person show they are distressed and what are the triggers?
What does the child/young persons behaviour look like in a meltdown/withdrawal?
When in meltdown/withdrawal can the child/young person be easily distracted?
Yes
No
How can the child/young person be distracted?
Does the child/young person demonstrate any repetitive or obsessive behaviours?
Yes
No
N/A
Does the child/young person have a good or poor self-esteem?
Good
Poor
What does the child/young person do to make you think this?
Does the child/young person display symptoms of anxiety?
Yes
No
How does the child/young person display this?
What are the child/young persons sleeping patterns?
Any additional comments around sleep, behaviour, self-esteem or anxiety
Health, safety and risk accommodations
Does the child/young person need wheelchair access?
(Required)
Yes
No
Does the child/young person carry an Epi Pen?
(Required)
Yes
No
Is the child/young person likely to demonstrate any aggressive or violent behaviours whilst with the therapist?
(Required)
Yes
No
What behaviours could the child/young person demonstrate?
(Required)
Will the child/young person need to be separated from other families due to anxiety or behaviour?
(Required)
Yes
No
Why will the child need to be separated from other families?
(Required)
Any additional information we may need (i.e. family background)
Name
This field is for validation purposes and should be left unchanged.
