This form serves as a starting point for the assessment of the child. Please assist us in providing the following information about your child. This questionnaire need to be completed by parents or caregivers.

INSTRUCTIONS

1. Please provide as much information as possible. You may leave a block open when not applicable.
2. Just type the information into the spaces provided.
3. The small rectangular boxes are clickable. Make a selection by clicking on the applicable box.
4. Fields marked with a * are mandatory.

Please note that the information supplied will be handled in a strictly confidential manner. It will only be used by Wietske Boon for the intended use. It will not be supplied directly or indirectly to any third party without the written permission of the parents or caregivers of the child. This information is not stored on the Internet.

PERSONAL INFORMATION

Name of child: *

Date of birth Age Gender

FAMILY COMPOSITION
(Please give information concerning parents, stepparents, foster parents or care givers)

Please provide names and surnames of each.

Father:
Date of birth
Mother:
Date of birth
Child1:
Date of birth
Child2:
Date of birth
Child3:
Date of birth
Child4:
Date of birth
Address:
Postal code:
Telephone:
Cell no:
Email:

Please provide the information regarding the second family in the case where the biological parents were divorced and remarried.

Please provide names and surnames of each.

Father:
Date of birth
Mother:
Date of birth
Child1:
Date of birth
Child2:
Date of birth
Child3:
Date of birth
Child4:
Date of birth
Address:
Postal code:
Telephone:
Cell no:

Living arrangements. Please click the appropriate box.

Living with biological parents
Living with single parent.
Living with step parent(s)
Living with foster parent(s)
Adopted
Father/mother in unmarried relationship i.e. living together.
Other

Period of this arrangement: Years: Months:
Reason for referral?

INFORMATION ABOUT THE CHILD

Pregnancy: Planned Unplanned
Birth Process: Normal birth Caesarean section
 
Premature birth
 

Remarks (e.g. child born after death of a child, infertility treatment, etc:

Medication used during pregnancy:

Did the mother use any of the following during pregnancy?

Alcohol
Drugs
Smoking
Childhood illnesses the child had:

Does the child have any chronic illnesses (eg diabetes, cancer.etc)? Please specify:

Does the child have any allergies? Please specify:

Does the child use any medication or supplements?

Is the child hyperactive or does he/she has difficulty to concentrate?
Yes
No

Development milestones (age):

Sit
Crawl
Stand
Walk
First words

With whom did the child bond as baby? (Mother, father, caregiver, etc)

With whom does the child bond now?

List the child's positive and negative personality traits:

Positive traits Negative traits

Behaviour of the child that concerns you (eg. jealousy, aggression, etc)

What means of punishment do you use and how does the child react to it?

Is the child experiencing any eating problerms?
Yes
No
Is the child experiencing any sleeping problerms?
Yes
No

Does the child have any habits (eg. biting nails)?

Did the child wet his/her bed?
Yes
Age

Does the child experience any other problems?

Name of school/daycare
Grade

Name of teacher

Has your child been tested for scholastic performance?
Yes
No


Does your child participate in extra mural activities? Please specify.

The child's relationship with the parents or caregivers


What do you and your child do together?

What do you and your child fight about?

Describe the child's relationship with other family members.

Did anything happen that can be linked to the onset of difficulties?

Is the child more sad, aggressive, depressed etc. than before?

Did any significant behavioural/personality changes occur during the past few weeks?

Name your religion

Does your religion play a significant part of the child's life?
Yes
No

Are there any cases of alcohol misuse in the family?
Yes
No

Does your child own pets?
Yes
No

Who is responsible for the pets?

Therapy

Who referred you?

What do you expect from therapy?

Completed by:

Date:

Your email address:

Please press the "Submit form" button only once - it will take a few seconds to complete the submission