www.psyched.co.nz
CASE HISTORY
Childs Details:
Name
Date of Birth
Age:
Sex:
Address
Phone No
School
Class
Teacher
Interests (hobbies, sports)
Parent Details:
Mothers Name
Occupation
Phone (Work)
Mobile:
Fathers Name
Occupation
Phone (Work)
Mobile:
Reason/s for Referral:
e.g. difficulty with reading, spelling, maths, writing, listening, attention, concentration, memory, organization, listening, sitting still, behaviour; identify giftedness.
Has your child received prior evaluation for the referral problems?
Medical:
Please tick in the box and give details if your child has had any of the following:
Recurring Ear Infections
Hearing problems
Vision problems
Head injury
Serious falls/accidents
Been hospitalized
Serious illness
Prenatal/Postnatal: please outline any difficulties during pregnancy or birth of referred child (e.g. low birth weight, premature, forceps, caesarean, oxygen required)
Developmental:
Please tick in the box and give details if your child has had any difficulty with the following:
Language development (e.g. learning to talk, speech, listening, understanding instructions, sensitivity to noise)
Fine motor development (e.g. tying shoelaces, getting dressed/buttoning, using knife, fork, pencil, pen, scissors, drawing, doing puzzles, lego)
Gross motor development (e.g. crawling, walking, running, jumping, balancing, throwing or kicking a ball, clumsiness, riding a bike, coordination)
Do any family members have learning/reading problems? (e.g. parents, siblings)
Behavior/Social:
Please tick in the box and give details if your child has had any difficulty with the following:
Behaviour at school
Behaviour at home
Getting along with others (teachers, family members, friends)
Concentrating
Sitting still
Waiting
Self-control
Organisation (e.g. setting out work, having items ready to do school/home work)
Remembering (e.g. to take items to school, bring items home)
Motivation, interest, attitude to school/home work
Self-confidence
Educational:
Please list names and dates of previous early childhood centres and schools attended.
Has your child been identified by their school as needing any special help?
Is your child presently (or in the past) on any special programme or receive special help at either their school or out of school? (e.g. Reading Recovery, Rainbow Reading, Teacher Aide, extension programs, One Day School, Tutoring, Number Works)
Has your child previously been identified or diagnosed by a professional as having any specific difficulty? (e.g. dyslexia, dypraxia, ADHD). If yes, please provide details.
Please provide (list here or bring copies to first assessment session as appropriate) any other information that may be relevant to your child's referral (e.g. school records, previous assessment results, PAT's results, copies of all school reports, samples of written work and drawings)
I
Thank-you for completing this form, the information you have provided will help with the assessment of your child.
