Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Age
Gender
*
Which is the child's predominant hand?
Right
Left
Both
Country of Birth
*
Language spoken at home
Name of person completing the form
Alcohol/drugs used during pregnancy
Was baby early/late/on time?
Did baby turn blue?
Child’s birth weight
Other post-birth problems?
Was there any difficulty with feeding when the child was a baby?
Did the child sleep well as a baby?
As a baby was the child difficult to soothe?
As a baby was the child overactive?
At what age did the child first sit up without assistance?
At what age did the child first crawl?
At what age did the child first walk alone?
At what age did the child say their first words eg "mum"or "dada"?
At what age did the child begin saying 2-3 word phrases eg "I want drink"?
Dates the child's hearing has been tested.
Dates the child's eyesight has been tested.
Name of Class Teacher
Name of School Principal
Name of School Psychologist
Is the child currently enrolled in a special class?
List the child's brothers and sisters
Include their ages as well please
Mother's Name
First Name
Last Name
Mother's country of birth
Please confirm if the child's 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.
Mother's occupation
Father's Name
First Name
Last Name
Father's country of birth
Please confirm if the child's 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.
Father's occupation
Other Primary Carer's
First Name
Last Name
Current concerns and questions you would like answered by this assessment:
Is this assessment forming part of a claim for funding under the NDIS?
