Your Child's Name
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First Name
Last Name
Your Child's Date of Birth
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Parent/Guardian Name
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First Name
Last Name
Mobile
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Email
Emergency Contact Name
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First Name
Last Name
Mobile
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(###)
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Email
Family Information (siblings, ages, family history of developmental concerns)
Birth and Early Development (prematurity, complications, c-section, developmental milestones)
Medical History /Diagnosis
Has hearing and vision been tested and what was the outcome?
What is your child's primary method of communication (verbal, gestures, AAC user)
Name of childcare / school and phone number
Name of teacher and email
Past/Present Therapy (physical therapy, speech and language services, counselling/psychology)
What are your child's strengths and interests?
Do you have concerns with your child's eating, drinking, or participation in mealtimes?
Do you have concerns with your child's participation in selfcare routines such as dressing, undressing, bathing, toileting?
Do you have concerns with your child's sleep routine? If so, please describe current routine.
How does your child manage friendships and social situations?
Please describe your child's play and preferred activities (independent play, playing near others, cooperative play with others, favorite toys or activities)
Do you have concerns with your child's gross motor skills? (balance, walking, running, throwing, catching, coordination)
Do you have concerns with your child's fine motor skills? (managing and playing with small objects, writing and coloring, cutting, grasp patterns)
Do you have concerns with your child's social/emotional skills or behavior? (managing emotions and frustration, challenging behaviors, handling transitions and changes in routine). If so, please describe.
What are the main concerns you have for your child at this time?
Please provide the name and contact details for your child's team members:
Speech Pathologist, Psychologist, Paediatrician, other:
Is there any other information you would like to share about your child?
Form completed by:
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First Name
Last Name
Date
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