Under 18’s Pre-assessment questionnaire

Pre-Assessment Questionnaire – Under 18’s

Step 1 of 10

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X/Twitter

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

We are currently getting back to families within 3 weeks of receiving the completed enquiry 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

Parent/Carer details

Have you or the person you are completing this form for, or their parent or carer, ever served or are currently serving in the armed forces?(Required)

Yes

Parent/Carer Name(Required)

Title First Last

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

Relationship to child/young person(Required)

Additional Parent/Carer Name

Title First Last

This is to provide us with additional contact information if needed.

Would you like to provide a written pronunciation of the second parent/carer name

Relationship to child/young person

Relationship status of parent/carers(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)

Does your child or young person have any siblings?(Required)

Yes

If yes how many?(Required)

How did you hear about bibic?(Required)

If other please specify(Required)

Child/Young person's details

Child/Young Person's Name(Required)

First Last

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

Nickname

Date of birth(Required)

DD slash MM slash YYYY

Gender(Required)

Child/ young person's preferred 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)

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)

Independence

Social (Interacting with others)

Sensory Processing

Memory and auditory processing

Behaviour

School (ability to manage in a classroom environment)

Visual

Other

If other please specify(Required)

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

Do they have any known diagnosis?(Required)

Yes

If yes please provide more details including dates(Required)

Do they have any suspected diagnosis?(Required)

Yes

If yes please provide more details(Required)

Please provide details including dates of any tests or screenings that have been completed within the last 2 years.(Required)

Were they born before 37 weeks?(Required)

Yes

Health and Safety

Is your child/young person likely to display verbal aggression whilst in the centre?(Required)

Very unlikely

Somewhat unlikely

Somewhat likely

Very likely

Please specify(Required)

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

Very unlikely

Somewhat unlikely

Somewhat likely

Very likely

Please specify(Required)

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

Very unlikely

Somewhat unlikely

Somewhat likely

Very likely

Please specify(Required)

Is there a risk of harm to the child/young person?(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 of those 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 their 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 their hearing?(Required)

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

Speech and language – Expression

How do they communicate with you and others?(Required)

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

Speech and language – Understanding

Can they be literal?(Required)

Yes

If yes please provide more details(Required)

Do they understand time concepts?(Required)

Are they 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 their mobility?(Required)

For example, sitting, crawling, using aids, walking, are they developmentally inline with their peers, are they hypermobile, muscle tone

Do they have good balance and coordination?(Required)

Have they got good spatial awareness?(Required)

Can they ride a bike, scooter, skateboard etc?(Required)

Can they throw, catch and kick a ball?(Required)

Throw

Catch

Kick

None of the above

Fine motor (hand and finger control)

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

For example, what is their hand writing like, can they pick up items, what is their dexterity like, how is their pen/pencil grip

Sensory Processing

Can they be sensitive to sound?(Required)

Can they be sensitive to touch?(Required)

Can they be sensitive to smells?(Required)

Can they be sensitive to light?(Required)

Do they seek or avoid movement?(Required)

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

Any additional information regarding sensory processing(Required)

Learning

Please tick what setting they are attending(Required)

Nursery mainstream

Nursery specialist

Childminder

Pre-school mainstream

Pre-school specialist

School mainstream

School specialist unit

School Not currently attending

School Part time

School Boarding

School PRU

School Private

School Hospital

Home educated

College Mainstream

College specialist

Other

If other please specify(Required)

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

How do they manage in this setting, including their behaviour?(Required)

How do they engage with learning?(Required)

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

Are you suspecting Dyslexia?

Yes

Do they receive any additional support?(Required)

Yes

If yes please tell us what support they receive?(Required)

Are they able to read?(Required)

Yes

If yes do they understand what they read?(Required)

Any other information(Required)

Do they like reading, are they confident, are they inline with their peers

Daily living tasks and life skills

Tell us about their sleep(Required)

Tell us about their self-care(Required)

Feeding, dressing, toileting, personal hygiene

Is their understanding and management of money age appropriate?

Are they able to travel independently, if age appropriate?

Additional comments regarding life skills(Required)

Making appointments, organising themselves, can they organise the resources they need

Behaviour

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

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

Tell us about their emotional wellbeing(Required)

Anxiety, self-esteem

Social development

Tell us about their social development(Required)

Friendships, play, imagination, interaction with others, safety awareness

Do they understand social codes of conduct?(Required)

Yes

If yes can they follow them?(Required)

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

What makes them happy?(Required)

What are their interests and hobbies?(Required)

What are their strengths?(Required)

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