INFORMATION QUESTIONAIRE
Norwood Education - Confidential
We would be grateful if you would take the time to complete the following. It will help us to know how to
help your child and support your family. Please complete all relevant sections.
Section 1
Important Contact Details
Surname: ..........................................................................
First name: ........................................................................
Other names: ....................................................................
Date of birth: .....................................................................
School Year Group:………………………………………
Age at Referral ………………………………………………
Gender:
Male
Female
Address: ...........................................................................
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Parents/Guardians contact details
Surname
Surname
First Name
First Name
Relationship to
client
Relationship to
client
Occupation
Occupation
Home Tel:
Home Tel:
Mobile
Mobile
Work Tel:
Work Tel:
Email
Email
Page 1 of 15
Please attach photo here
(Optional)
GP
Name:
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Address:
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Tel No:
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Contacts in case of Emergency
Name
Tel Numbers
1
2
School
Name:
............................................................... ...
Address:
............................................................... ...
Tel No:
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Name of Head Teacher:
.................................................. ....
Name of SENCO:
................................................. ......
Please indicate the type of placement:
Nursery/Playgroup
Mainstream secondary
Mainstream primary
 
Special school
Other (Please specify): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
In which Local Authority is your home: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
In which Local Authority is the school: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Section 2
Child and Family Information
Names, date of birth and gender of siblings:
Name
Date of Birth
Gender
Language(s) spoken at home:
...............................................
Religion: (Optional)
............................................ ..
Has any member of the family had:
a) A learning Difficulty
Yes
No
b) Speech and Language difficulties
Yes
No
c) Other difficulties
Yes
No
If yes, please explain:
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..............................................................
Please circle all traits that apply to your child now:
Sad
Happy
Leader
Quiet
Overactive
Independent
Affectionate
Trouble Sleeping
Fearful
Follower
Co-operative
Hard to discipline
Moody
Dependent
Tantrums
Sensitive
Lethargic
Even tempered
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Friendly
Too responsible
Prefers to be alone
What are your child’s strengths?
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What are his / her interests / likes?
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Professional Diagnosis
Does the applicant have a diagnosis?
If yes please specify:
Yes
No
.........................................................
If yes, from whom and when: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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What follow up treatment has (s)he received and when? Was this useful?
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Section 3
Reason for Referral
Please can you describe your child’s difficulties? What is the greatest area of concern?
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I would like you to help my child with:
(Please tick as many boxes as apply)
Organisational skills
Motor Skills e.g. drawing
Writing
Clear speech
Memory
Reading
Problem solving/reasoning skills



Understanding instructions
Communication – expressing ideas and opinions

Emotional needs
Appropriate response in social situations/social skills/making ps
Behaviour needs including any concerns with sleeping
Advice:

Parenting support and advice
 
Teach how to work with my child/advice for school
Other please specify:
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If our services are helpful, what would have changed?
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Section 4
Education
Does the applicant have a Statement of Special Educational Needs/Education Health and Care Plan, or
are you in the process of obtaining one?
Yes
No
If yes, please give details:
.............................................................. ..............
.............................................................. ..............
Has your child ever received or is he/she currently receiving additional support, e.g. Social Skills Group,
Literacy Groups?
Yes
No
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If so, what and when?
In School: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Privately: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Some of the following may not apply to your child. Please fill in relevant sections:
Basic Concepts
Please rate your child’s abilities in the following areas compared with other young people of the same
age:.
Good command
Fair command
Unable to do
Letter recognition
Number recognition
Shape recognition
Colour recognition
Educational Abilities
Please rate your child’s abilities in the following areas by ticking the appropriate box. Even if your child
can do only some or none of these activities please complete the whole table.
Can do as well/better
than peers
Can do but not as
well as peers
Unable to do
Reading
Writing (Kodesh/Secular)
Comprehension
Addition
Subtraction
Multiplication
Division
Recent Assessments
Please give details of most recent assessment (either in UK or elsewhere; who seen, where, when)
Medical reports, Education reports and those about your child’s wellbeing are all helpful.
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Most recent school examination results:
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Section 5
Child’s Developmental History
Labour and Delivery
Was the birth “normal”?
Yes
No
If No, please explain: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.............................................................. ....................
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Were there any problems related to pregnancy labour or delivery?
Yes
No
If yes, please explain: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Mother’s age at birth of child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Father’s age at birth of child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Perinatal History
Did mother or baby stay in Special or Intensive Care?
Yes
No
Please describe any problems:
.................................................................................
.............................................................. ....................
Infancy and Early Childhood Behaviour
Please circle one
As an infant
Alert
Quiet
Active
Passive
Irregular sleep
Stable sleep patterns
Cried a lot, fussy
Non-demanding,
good
Resisted being
Enjoyed being held
held
Tense when held
Floppy when held
At present
Alert
Quiet
Active
Passive
Irregular sleep
Stable sleep patterns
Cries a lot, fussy
Non-demanding,
good
Resists being held
Enjoys being held
Tense when held
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Floppy when held
Other problems or comments regarding infancy or early childhood development:
........................................................... .......................
Do you think any event, health condition, separation etc. disturbed early infant/parent bonding or the
developing toddler/parent relationship?
Yes
No
If Yes, please explain: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Ages at Milestones
Gross Motor:
roll over
crawled
Fine Motor:
fed self with spoon
scribbled
Language:
used single words
used sentences (2+ words)
Social/Adaptive: potty trained/day
Section 6
stood alone
walked alone
ran well
showed hand preference
described activity
potty trained/night
Medical History
Young person’s current health is:
Poor
Fair
Good
Excellent
Medical treatment since birth:
Has the applicant been taken to the emergency room with a serious emergency, hospitalized, or had
Outpatient surgery since birth?
Yes
No
If Yes, please describe condition/injury, treatment, any surgery, when, how long, and where.
.............................................................. ....................
..................................................................................
Medical illnesses and/or allergies:
Does he/she suffer from medical illnesses or allergies?
Yes
No
If yes, please specify: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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If the applicant has had a head injury
Did he/she lose consciousness
Yes
No
How long? . . . . . . . . . . . . . . . . . . . .
Hearing and Vision
Date of last hearing test:
............................................................
Were the results normal?
Yes
No
If No, please explain: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Does he/she have grommets?
Date of last vision test:
Yes
No
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Does the applicant wear glasses/contact lenses?
Yes
No
If Yes, please give details: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Section 7
Behaviour and Emotional Well-Being
General Behaviour
Does your child struggle more than other children with controlling their behaviour?
Yes
No
Please describe any concerns you or others have about your child’s behaviour or emotional well-being:

At home
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
At school
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How well does your child get on with others?
Well
OK
Not well
Siblings
Other Children
Adults
What is your child’s attitude to school?
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Social Impact
Please list any unusual, traumatic, or possibly stressful events in the child and family’s life that you think
may have had an impact on his or her development and current functioning, e.g. moving country,
relationship changes etc. Include incident, student’s age at the time, and comments. (Continue on
another sheet if needed).
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Is he/she aware of any difficulties?
Yes
No
If Yes, how does your child feel about his difficulties?
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Mental Health Support/Treatment
Has the child or the family received any professional psychological support, such as individual or family
counselling, group counselling, etc?
Yes
No
If yes, please list any past and current treatments, including type of counselling, person counselled,
name of counsellor, and length of treatment.
..................................................................................
..................................................................................
Were they useful and why?
Yes
No
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Section 8
Communication and Motor Skills
Communication – Speech and Language
Does your child have any difficulty in the areas of speech and language?
Yes
No
If Yes, please explain
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If more than one language is spoken in the home, are these difficulties evident in both languages?
Yes
No
Does your child have difficulty with any of the following?
English
Yes
No
Yes
No
Comment/Example
Speech/pronunciation
Expressive skills - to use
words or sentences
Tendency to stammer
Listening to or following
instructions
Understanding language
Other home language, if
applicable Please specify
language:
......................
Speech/pronunciation
Expressive skills - to use
words or sentences
Tendency to stammer
Listening to or following
instructions
Understanding language
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Comment/Example
Other aspects of
communication
Yes
No
Comment/Example
Poor eye contact/avoidance
of social interaction
Poor communication
skills/difficulty
Using language socially
Language used is
bizarre/repetitive/not always
relevant to the conversation
Co-ordination and Independence Skills
Does your child have difficulty with any of the following?
Skill
Fine motor skills –
small movements, such
as cutting, writing etc.
Gross motor skills –
large movements, such
as walking, running,
jumping, climbing
Visual perception skills
– understanding what
he/she sees
Dressing
Touch – Doesn’t like to
be touched, avoids
messy tasks
Use of Cutlery
Handwriting
Yes
No
Comment/Example
Is your child left handed/right handed/ ambidextrous/unsure
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Section 9
Documents Required
We would also like you to send us the following information:
 Copies of the following reports:
- Medical
- Therapy
- Psychology
 A copy of your child’s:
- Statement of Educational Needs/Education Health and Care Plan
- Individual Education Plan
- Any other relevant reports from school
 Have you attached a photograph? (Optional)
Section 10
Additional Information
If you would like to add a written statement in your own words, this can be helpful.
Section 11
NORWOOD EDUCATION SERVICES
How did you hear about the Hope Centre/BINOH?
Know someone who attends

Website

Recommended
Please specify . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Doctor/Psychologist
Please specify . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Local Authority
Please specify . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Magazine
Please specify . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Other
Please specify . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Section 12
Professionals and agencies involved with your child
Name
Period of
involvement
Paediatrician
ENT Consultant
Other Consultant
Speech & Language
Therapist
Occupational
Therapist
Physiotherapist
Alternative Medical
Practitioner (please
specify)
Psychiatrist
Clinical Psychologist
Psychotherapist
Educational
Psychologist
Social Services
Norwood
Binoh
Hope
Private Tutor
Rebbe
Other
Page 14 of 15
Phone
number
Current?
Yes/No
Section 13
Signature and Consent Form
In order to provide you with a service, we may need to talk to other agencies involved with your family,
both to gain and share information. Please be aware that all Children’s’ Services within Norwood, which
include Family Support, Education and Social Work, work together and information is shared. Norwood
will store and will share relevant information between its professionals to support your child/children,
following the requirements as stated by law in the Data Protection and Freedom of Information Acts
(1998).
In order to proceed with the referral please sign below.
I/We understand and give consent that only information that relates to this referral will be
requested/shared.
:
Signed: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Parent /Guardian/Other
(Please delete as appropriate)
Name: (please print) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Date: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Please Return Form to:
Kennedy Leigh Centre
Edgeworth Close
Hendon
London
NW4 4HJ
Tel: 020 8457 4745
Fax: 020 8203 8233
[email protected]
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