Pre-Assessment Questionnaire

Step 1 of 13

Form completed by(Required)

First Surname

Date completed(Required)

DD slash MM slash YYYY

Child/young person's name(Required)

First Surname

Parent/carer name(Required)

Title First Surname

Parent/carer name

Title First Surname

Marital status of parents(Required)

If other, please specify

Step parent/s name if applicable

Title First Surname

Does the child/young person have any siblings(Required)

Siblings, name, age and any known diagnoses(Required)

Does the child/young person have a known diagnosis?(Required)

Please provide details of diagnosis and date confirmed

Does the child/young person have any suspected Diagnoses?

Do you/child/young person/family have any professionals involved?(Required)

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)

Please list any health conditions or allergies and please list any medications

Does the child/young person take any medications?

Please list any medications

Were there any complications before, during or after pregnancy?(Required)

Including premature birth, low birth weight, assisted birth?

Was the child/young person born prematurely?

Did the child/young person have a low birth weight?

Were ventouse or forceps used?

Was the child/young person sent to NICU or kept in hospital?

Did the child/young person inhale any meconium?

Was the birth Natural or Caesarean?

Was the caesarean planned or emergency?

Were there any difficulties with breast or bottle feeding?(Required)

What are your three main concerns?(Required)

Fine motor (Handwriting, tasks with hands)

Gross motor (Movement, mobility, balance and coordination)

Language comprehension (understanding language)

Expressive language (communicating)

Academic (reading, writing, maths)

Independence

Social (interacting with others)

Sensory Processing

Memory and auditory processing

Behaviour

School (ability to manage in a classroom environment)

Visual

Other

Please select three

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)

Date of eye test

DD slash MM slash YYYY

Does the child/young person wear glasses?(Required)

Has the child/young person had a hearing test?(Required)

Date of hearing test

DD slash MM slash YYYY

Is the child/young person five years or younger chronologically or developmentally?(Required)

Does the child/young person show recognition to familiar people or toys?

Does the child/young person react to visual stimuli?

Does the child/young person react to auditory stimuli?

Does the child/young person mishear things?

Does the child/young person use strategies to manage noise levels (humming, covering ears, ear defenders)

Is the child/young person sensitive to light(Required)

Does the child/young person struggle with reading due to visual disturbances?(Required)

Any additional comments around vision and hearing

Speech and Language

Is the child/young person verbal or non-verbal?(Required)

How does the child/young person communicate? (PECS, Makaton, Signs, Symbols)

Does the child/young person make vocalisations?

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?

Does the child/young person's difficulties with speech and language cause frustration?

Can the child/young person express their needs?

Can the child/young person express their emotional needs?

Can the child/young person hold a conversation?

Does the child/young person use alternative forms of communication such as texting?

Any additional comments around speech and language

Comprehension

Does the child/young person respond to others communicating with them?(Required)

Can the child/young person be literal?

Does the child/young person understand time concepts?

Can the child/young person follow simple instructions?

Can the child/young person follow a set of instructions that are more complex?

Does the child/young person understand what they read?

Does the child/young person understand social codes of conduct?

Does the child/young person understand the nuances of language?

Is the child/young person affected by tone of voice?

Does the child/young person understand facial expressions and body language?

Does the child/young person look at the person talking to them?

Does the child/young person respond to their name being said?

Can the child/young person follow key instructions such as sit or stop?

Does talking to the child/young person soothe them?

Any additional comments around comprehension

Gross Motor Skills (big movements)

Is the child/young person mobile (independently)?(Required)

Did the child/young person crawl?

Date first crawled

DD slash MM slash YYYY

Did the child/young person commando crawl or bum shuffle?

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?

Does the child/young person have good spatial awareness?

Can the child/young person swim?

Can the child/young person ride a bike?

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?

Can the child/young person sit?

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?

When lying on the floor does the child/young person's head stay in midline, lean to the right or lean to the left?

Does the child/young person partake in any physical therapies?

Any additional comments around gross motor skills

Fine Motor

Is the child/young person mark making or writing?(Required)

Is the child/young person left or right handed?

Does the child/young person have an effective pencil grip?

What is the quality of the child/young persons writing?

Please indicate what cutlery the child/young person can use skilfully

Knife

Fork

Spoon

Can the child/young person manage fastenings such as buttons, laces and zips?

Can the child/young person dress and undress themselves independently?

Can the child/young person brush their teeth independently?

Can the child/young person brush their hair independently?

Does the child/young person need reminding to do self-care tasks?

Can the child/young person reach and grab items?

Can the child/young person point at objects or people?

Does the child/young person explore their surroundings with their hands?

Are the child/young person's hands open or closed?

Can the child/young person feed themselves?

Is the child/young person peg fed?

Can the child/young person hold a bottle or cup?

Does the child/young person attempt to help when dressing or undressing?

Any additional comments around fine motor

Sensory Processing

Does the child/young person have sensory processing difficulties?(Required)

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?

Does the child/young person seek tactile input such as messy play?

Is the child/young person a fussy eater?

Does the child/young person only eat certain tastes?

Does the child/young person only eat certain textures?

Does the child/young person separate their foods?

Does the child/young person reject foods typically eaten by children?

Is the child/young person constantly moving or fidgeting?

Does the child/young person hand flap, chew fingers or lips, pace or bounce?

Is the child/young person over sensitive to smells?

Does the child/young person prefer low lighting?

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

If the child/young person is attending a setting please provide us with the name and address of the setting(Required)

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

We ask for this information so we can inform the setting that you are coming to us for an assessment and what your assessment dates are, to open communication between professionals.

If not attending a setting please provide us with their GP name and address(Required)

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

We ask for this information so we can inform the GP that you are coming to us for an assessment and what your assessment dates are, to open communication between professionals.

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)

Please provide us with what support the child/young person receives.

Does the child/young person have difficulties concentrating or engaging?(Required)

Does the child/young person struggle to change task or change their focus?(Required)

Does the child/young person have difficulties with planning, organising and independence?(Required)

Does the child/young person manage toileting independently?(Required)

Is the child/young person over the age of 16 years?(Required)

Can the young person manage to organise their daily lives?

Can the young person plan/manage their time effectively?

Can the young person manage their own finances?

Can the young person organise their own appointments?

Any additional comments around learning, working, development and independence

Social development

Which age bracket does the child/young person fall in?(Required)

Does the child show interest in others?

How does the child interact with others?

Is the child happy to explore their environment independently?

Does the child respond well to routine?

Does the child have an awareness of cause and effect?

Is the child's play repetitive?

Does the child have a favourite toy or activity?

What is the child's favourite toy or activity?

What makes the child happy?

Does the child/young person engage in imaginative play?

Is the child/young persons play mimicked from things they have seen or watched?

Does the child/young person prefer to play independently or in a group?

Does the child/young person have good safety awareness?

Does the child/young person have good stranger danger awareness?

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?

Does the young person socialise regularly?

Can the young person plan social events?

Are the young person's friends the same age?

Are the young person's friends mostly online?

Does the young person have good safety awareness?

Does the young person have good stranger danger awareness?

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)

Does the child/young person have good or poor sleeping patterns?

What does the child/young persons sleeping patterns look like?

Does the child/young person sleep in their own bed?

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?

How can the child/young person be distracted?

Does the child/young person demonstrate any repetitive or obsessive behaviours?

Does the child/young person have a good or poor self-esteem?

What does the child/young person do to make you think this?

Does the child/young person display symptoms of anxiety?

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)

Does the child/young person carry an Epi Pen?(Required)

Is the child/young person likely to demonstrate any aggressive or violent behaviours whilst with the therapist?(Required)

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)

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.