CESD Office Use Only
Date Received
SS Signature
Psychologist
2016-2017 PARENT/GUARDIAN INPUT FORM
FOR PSYCH-ED ASSESSMENT
Child’s Name:
Today’s Date:
School:
Birthdate:
Grade:
Gender:
□ Male
□ Female
Home Address:
Age:
Postal Code:
Guardian/Mother’s Name:
Occupation:
Phone #
Guardian/Father’s Name:
Occupation:
Phone #
Stepfather:
Occupation:
Phone #
Stepmother:
Occupation:
Phone #
If parents are not together, when did separation occur:
Primary Language Spoken at Home:
Was your child adopted?
□ Yes
Is/Was your child in protective custody?
□ No
□ Yes
Does your child know?
□ No
If yes, at what age and for how long?
Who else lives in the home with your child? (e.g. step- siblings, siblings, grandparents, aunts, etc.) List their names, ages and relationship.
STRENGTHS AND PREFERENCES
Please write a brief description your child including positive personality characteristics, preferred activities and areas of achievement.
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28/07/2017
PRESENTING PROBLEM
Please describe your child’s difficulties.
For how long has this been a concern to you?
What helps the problem?
What makes the problem worse?
What changes (if any) have you noticed recently?
Has your child ever been evaluated or treated for the current problems or similar problems? If yes, please explain.
Is your child being treated at present for any illnesses, medical or otherwise? if yes, please describe.
Is your child taking any medication at this time? If yes, please describe.
Has your child ever received counselling supports? If yes, please describe when and what for.
Has your child previously undergone a psychological assessment?
If so, please attach a copy of the assessment report(s).
Please indicate any specific questions you would like answered by this assessment?
ACADEMIC CONCERNS
Did your child attend:
Pre-School/Play School
Has your child ever been held back a grade?
Kindergarten
If so, please indicate grade and reason.
Has your child been involved in specialized programming? (e.g. ASPIRE, Early Lit, Social Skills Group, Speech, OT, PT)?
If yes, please describe.
Has your child’s school performance declined recently?
How many days of school did your child miss over the last year?
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If so, please explain.
If numerous please explain.
28/07/2017
DEVELOPMENTAL HISTORY
Describe any problems during pregnancy and delivery?
Did the mother consume alcohol during pregnancy?
When was the alcohol consumed?
Please describe.
□ 1st trimester
□ 2nd trimester
□ 3rd trimester
Were there any drugs (prescription or otherwise) consumed during pregnancy?
If yes, please describe.
How many weeks gestation at delivery of your child?
Birth weight
Describe birth defects or complications (if any).
At what age did your child do the following? Please indicate year/month of age (best guess).
Turn over
Walk up stairs
Walk down stairs
Speak first words
Sit alone
Walk alone
Crawl
Speak in sentences
Has this child experienced any of the following problems? .
Unclear speech
Weight problems
Motor skill problems
Appears immature
Difficulty making friends
Requires constant supervision
Motor or vocal tics
Frequent Migraines
Sexually inappropriate behaviour
Eating problems
Sleep problems
Toileting or bed wetting problems
MEDICAL HISTORY
Please place a check mark next to any of the following that apply and then provide any relevant details.
Illness or Condition
Age
Description
Encephalitis
Meningitis
Diabetes
Fainting Spells
Memory Problems
Eye Problems
Suicide Attempt(s)
Extreme Fatigue
Headaches
Convulsions
Seizures
Asthma
Describe other serious illnesses (if any)
Has your child been hospitalized?
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If yes, please explain
28/07/2017
Describe any accidents
Has your child had a head injury?
Has your child ever lost consciousness?
If yes, please explain
If yes, please explain
Describe any emotional trauma your child may have experienced.
Please provide any additional information/comments you feel might be relevant.
CHECKLIST OF CONCERNS
Place a check mark next to each item that accurately describes the student. If you cannot evaluate an item, please write a question mark next to the box.
Cognitive
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Struggles to comprehend material/concepts
Has poor short-term memory skills
Has poor long-term memory skills
Struggles to understand and follow directions
Uses problem solving strategies inefficiently
Seems to generally learn slowly
Perceptual Motor
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Has poor auditory perception
Has poor visual perception
Has poor handwriting/penmanship
Appears clumsy and awkward
Has right-left confusion
Has poor gross motor coordination
Has poor fine motor coordination
Speech/Language/Academic
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Demonstrates poor expressive language
Has difficulty communicating
Uses immature vocabulary
Has poor math calculation skills
Has difficulty decoding words
Has poor reading comprehension
Has difficulty in producing rhymes
Has poor phonological awareness
Has difficulty with written expression
Uses poor grammar
Has poor spelling skills
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Social/Emotional/Motivational
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Gives up easily
Is easily frustrated
Demonstrates low interest in school work
Steals things
Avoids doing work in class
Fails to do homework
Presents with low self-esteem
Is socially isolated from peers
Has numerous physical complaints
Has limited social perceptiveness
Struggles to get along with other children
Demonstrates aggressive behaviour
Shows anger quickly
Appears immature for age
Is stubborn
Often appears anxious
Appears depressed or unhappy
Is uncooperative
Is upset by changes in routine
Struggles to appropriately accept criticism
Asks questions constantly
Requires more support than most peers
Requires constant supervision
Seeks attention constantly
Shows disruptive behaviour
Talks excessively
Gives in to peer pressure
Is self-critical
Has low expectation for academic success
Demonstrates wide mood changes
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