Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Age
Gender
*
Which is the predominant hand?
Right
Left
Both
Country of Birth
*
Language spoken at home
As a baby, at what age did you first sit up without assistance?
At what age did you start to crawl?
At what age did you first walk alone?
At what age did you say their first words eg "mum"or "dada"?
At what age did you begin saying 2-3 word phrases eg "I want drink"?
Did you have any sensory sensitivities as a child?
What was your style of play at around ages 5 and 6?
Imaginative? Repetitive? Sorting/organising?
Do you have any issues making friends?
If yes, what issues do you experience?
What was your ability to cope with changes?
Did you have any intense interest growing up?
During your education were you ever enrolled in a special class?
Please confirm if your mother has experienced any of the following issues: Learning Problems, Reading Problems, Maths Problems, Spelling Problems, Repeating a Grade at School, Speech Problems, Behaviour Problems, Depression, Mental Illness, Drug/Alcohol Problems, Neurological Problems, Autism and ADHD.
Please list any issues that the mother has experienced and timeframes.
Please confirm if your father has experienced any of the following issues: Learning Problems, Reading Problems, Maths Problems, Spelling Problems, Repeating a Grade at School, Speech Problems, Behaviour Problems, Depression, Mental Illness, Drug/Alcohol Problems, Neurological Problems, Autism and ADHD.
Please list any issues that the mother has experienced and timeframes.
Please confirm if any of your brothers or sisters have experienced any of the following issues: Learning Problems, Reading Problems, Maths Problems, Spelling Problems, Repeating a Grade at School, Speech Problems, Behaviour Problems, Depression, Mental Illness, Drug/Alcohol Problems, Neurological Problems, Autism and ADHD.
Please list any issues that the mother has experienced and timeframes.
Current concerns and questions you would like answered by this assessment:
Is this assessment forming part of a claim for funding under the NDIS?
