Dear parent, this page is used complimentary to the assessment. It serves as a historicity overview which will help me to understand the unique situation of your child better. Note any questions or uncertainties and we will gladly discuss it during consultation. Indicate ‘yes’ or ‘no’ by circling the relevant option.
All information will be regarded as confidential and treated as such.
Thank you for your cooperation.
Please write your name, address and telephone number in the space provided.
What is the career of both parents?
Child’s name?
Child’s age?
Child’s date of birth?
What is your greatest concern about your child’s behaviour or school work?
Who else outside of the family is concerned about your child, e.g. a teacher, doctor or occupational therapist?
What is your home language?
In which language is your child being educated at school?
What is your child’s greatest talent?
In which extramural activities does your child partake?
What is your child’s favourite way to spend his/her time?
When is your child the happiest?
Who is your family doctor?
May I contact your family doctor? If yes, please provide a contact number. / Yes / No / Please sign if you are granting permission.
I ______grant permission that
Elmarie Moss may contact our family doctor.
Signature:
In which school and grade is your child currently? What is the name of his/her teacher?
May I contact the teacher? If so please provide a contact number. / Yes / No / Please sign if you grant your permission.
I ______hereby grant permission that
Elmarie Moss may contact my child’s teacher.
Signature:
Does your child have any medical problem? If so please indicate or add.
· Headache
· Stomach ache
· Asthma
· Head injury
· Other / Yes / No / Please provide details if you marked ‘yes’.
Is there a family history of any language difficulties, reading problems, emotional problems or medical problems? / Yes / No / Please provide details if you marked ‘yes’.
Were there any complications during the mother’s pregnancy with the child? / Yes / No / Please provide details if you marked ‘yes’.
Was there any complication during the child’s birth? / Yes / No / Please provide details if you marked ‘yes’.
Did your child have any serious illnesses? / Yes / No / Please provide details if you marked ‘yes’.
Does your child have a history of hearing problems or problems with eyesight? / Yes / No / Please provide details if you marked ‘yes’.
Does your child wear spectacles? / Yes / No / Please provide details if you marked ‘yes’.
How old was your child when he/she reached the following milestones?
· Crawl
· Walk
· Talk
· Off nappies
Is your child left or right handed?
Has your child been evaluated by any other professional persons? / Yes / No / Please provide details if you marked ‘yes’.
May I contact this person to request a copy of the report if available? / Please sign if you grant permission.
I ______grant permission that
Elmarie Moss may contact ______.
Signature:
Has your child received any treatment or therapy for his/her problems? / Yes / No / Please provide details if you marked ‘yes’.
Does your child experience any problems with reading or other school work? / Yes / No / Please provide details if you marked ‘yes’.
Is your child disobedient or difficult to control at home? / Yes / No / Please provide details if you marked ‘yes’.
Is your child disobedient or difficult to control at school? / Yes / No / Please provide details if you marked ‘yes’.
Is your child unhappy, afraid, insecure or upset? / Yes / No / Please provide details if you marked ‘yes’.
Is your child unhappy, afraid, insecure or upset at school? / Yes / No / Please provide details if you marked ‘yes’.
Does your child experience any sleeping or eating problems? / Yes / No / Please provide details if you marked ‘yes’.
Does your child experience any problems with going to the toilet? / Yes / No / Please provide details if you marked ‘yes’.
Please list the day care-, preschool- and schools that your child attended with dates and duration. / ·
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Is your child in the top third, middle third or bottom third of his/her class in terms of general achievement?
Does your child sometimes refuse to go to school? / Yes / No / Please provide details if you marked ‘yes’.
Does your child like going to school? / Yes / No / Please provide details if you marked ‘yes’.
Please list all the people living in your home as well as their ages. / ·
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Do you think that any of the following changes in your child’s life could be contributing to his/her current problem?
· Change of school
· Being bullied at school
· Moving
· Illness in the family
· Unemployment of a parent
· Birth of a new sibling
· Adoption
· Conflict between parents
· Divorce
· Mourning
· Any other changes or conflicts in the home or at school / Please provide details.
Please provide a recent school report.
Is there anything else that you need to add? Use this space.
AGREEMENT
§ Appointments must be cancelled at least 24 hours before the consultation. If not the client will receive an account (R100 per consultation).
§ All appointments that take place outside of normal office hours (8:00-17:00) will entail R150 additional costs.
§ No telephonic consultations. Crisis situations and other problems will only be dealt with during scheduled consultations.
§ No consultations will take place if the account has not been settled.
§ It is in a child's best interest for both parents to be involved in the therapy process and for the therapist to have a good working relationship with both parents.
§ In case of divorced parents, the parent who requested the therapist’s involvement is responsible for providing the therapist with the written consent of the child’s other parent.
§ The therapeutic process differs from the process of forensic assessment. The information gathered during the therapeutic process is subjective, and therefore not the type of information used in reports for legal purposes. We will refer you to an independent practitioner, should you need recommendations for legal purposes.
§ It is imperative that a child's confidentiality be respected. Your child's therapist strives to respect your child's inner world when giving feedback on progress in therapy.
We take note of Article 42 of the Child Care Act, which obliges a therapist to report suspected sexual abuse of the client to a social worker or a member of the South African Police Service.
I, ______(Name & Surname) have read the abovementioned and undertake to abide by these regulations.
I, ______(Name & Surname) am aware that an ICD-10 code has to be submitted to the medical fund. I herewith consent to therapeutic intervention by Elmarie Moss (Educational Psychologist).
Name of the child: ______
Child’s date of birth: ______
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Signature of Parent Date
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Signature of Therapist Date
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Developed by Emmie Archer and Carl du Preez. Permission provided to Elmarie Moss to use the questionnaire (2010)