Please fill in all fields marked with an *
* Has your child attended preschool? YesNo
* Has your child repeated any class: YesNo
* Have you had any concerns about your child`s early development (e.g. walking, talking)?
* What are your main concerns (If any) about your child having this assessment?
* What are your child`s special talents/abilities?
Has your child been assessed by any of the following?
* Psychologist: YesNo
* Physiotherapist: YesNo
* Occupational Therapist: YesNo
* Speech and Language Therapist: YesNo
* Paediatrician: YesNo
* Did your child have a hearing test? YesNo
* Did your child have a sight test? YesNo
* Does your child have difficulties with any of the following?
Dressing/undressing YesNo
Tying shoelaces YesNo
Closing buttons YesNo
Managing cutlery YesNo
Hopping/jumping/skipping YesNo
Using playground equipment YesNo
Riding a bicycle YesNo
Using a scissors YesNo
Standing on one leg YesNo
Walking on walls YesNo
Using a scissors or pencil YesNo
* Does your child have difficulty with any of the following?
Has difficulty making friends YesNo
Playing with peers YesNo
Seems unaware of the rules of social conduct YesNo
Avoids taking part in team games YesNo
Gets agitated in crowded places YesNo
Seems reluctant to use playground equipment YesNo
Misinterprets what is said to them YesNo
Uses formal, adult like language YesNo
Gets irritated by certain clothing textures YesNo
Sometimes speaks with an unusual accent YesNo
Becomes upset when routines or plans are changed YesNo
Has elaborate routines YesNo
If has elaborate routines, please give more details
Any other information you think may be relevant
Consent
I/ We consent to a psychological evaluation of my/our child by Edward Joyce, Psychologist.
Names of Parent or Legal Guardian:
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