Parental Information Form

Child and
parents details

Name of child

Date of birth

GenderMaleFemaleOther

Name of parent(s)

Email address *
A copy of the completed form will be sent to your email address

Home address

Phone number

Mobile number

Data protection
& GDPR

The new European General Data Protection Regulation (GDPR) has changed the way companies store and use the data of clients; and is designed to place greater power into the hands of individuals and prevent companies holding your data longer than is necessary.

Box Psychology Ltd takes the use of data very seriously, we do not hold client data longer than is necessary for the completion of any work we undertake, unless instructed to, and do not sell any data to 3rd party companies.

The only reason we would use your data without your explicit permission is if we were required to by law.

As such we need you to complete this part of the form or we cannot proceed.

Compulsory
I hereby give permission for BOX Psychology Ltd to contact me using the data supplied above.
I hereby give permission for BOX Psychology Ltd to store the data supplied above for as long as is necessary to complete the relevant work in relation to this case.

Optional
I hereby give permission for Box Psychology Ltd to store the data contained in this form digitally for up to 18 months from the completion of this work should any further work be required; to save having to complete this form again.

Current and
proposed setting

Name of current school

Name of SENCO

Name of teacher

Phone number

Email address

Current school address

If you are requesting PPS to visit another school in order to assess the provision that school would offer for your child please complete the details below, otherwise please proceed to the next section.

Name of proposed school (if applicable)

Name of SENCO

Name of teacher

Phone number

Email address

Proposed school address

Background

1. Please describe the home and family situation, e.g. siblings, pets, type of home, etc

Birth history

2.1 Were there any complications during pregnancy or at the birth of your child? If yes please explain.

2.2 Was the pregnancy full term?

2.3 What was the birth weight?

Early history

3.1 Did your child breast or bottle feed, and were there any difficulties?

3.2 When did your child first smile?

3.3 When did your child first sit up on their own?

3.4 When did your child first stand on their own?

3.5 Did your child crawl or bottom shuffle?

3.6 When did your child first walk?

3.7 When did your child say their first words?

3.8 Were there any sleep problems?

3.9 What age was your child toilet trained?

Which of the following might best describe your child? (please tick if appropriate)

Medical and
health history

4.1 Does your child have an earlier diagnosis?

4.2 If so what was the diagnosis?

4.3 Did/does your child wear glasses or have visual problems?

4.4 Did/does your child have hearing problems?

4.5 Has your child had any significant childhood illnesses?

4.6 Does your child have any allergies?

4.7 Does your child have any bowel problems?

4.8 Is your child on any medication? (please list)

Has your child been seen by any other professionals? (if so please name)

4.10 If 'Other' selected, please provide the name and role

Play

5.1 Does your child ride a bicycle?

5.2 Can your child catch a ball?

5.3 Does your child tire easily after physical activity?

5.4 Does your child constantly fidget when on a chair?

5.5 Does your child enjoy rough play?

5.6 Does your child seek movement, e.g. running, jumping, spinning etc.?

5.7 What is your child's favourite play activity?

5.8 Will your child line toys/objects up?

5.9 Is your child interested in spinning objects, e.g. fans?

5.10 Does your child join in with others at play?

5.11 Does your child prefer his own company?

5.12 Does your child construct and play imaginary games?

Sensory

6.1 Does your child mind if they are accidentally touched?

6.2 Is your child irritated/angered if touched by others?

6.3 Does touch have to be on their terms only?

6.4 Do they have difficulty queuing/lining up?

6.5 Are they tentative in their approach to touching objects?

6.6 Do they point at objects?

6.7 Do they dislike having dirty hands?

6.8 Do they mind being barefooted?

6.9 Do they mind labels in clothes?

6.10 Do they like/dislike showering?

Eating

7.1 Is your child a good eater?

7.2 Is your child a picky or fussy eater? If so please list the foods they will eat.

Behaviour

8.1 Is your child constantly alert/vigilant/hyper?

8.2 Do they startle easily?

8.3 Do they cry easily/often?

8.4 Are they clingy?

8.5 Are they noisy in the presence of others?

8.6 Are they reluctant to try new things?

8.7 Are they compliant (do they do ask they are asked?)

8.8 Are they defiant? (if so please give examples)

8.9 Do they get aggressive? (if so please give examples)

8.10 Do they hurt themselves/others? (if so please give examples)

8.11 Are they moody?

8.12 Do they easily escalate into a high arousal state?

8.13 Do they get out of control?

8.14 Are they constantly agitated/on the go?

8.15 Are they impulsive?

8.16 Do they ever run off?

8.17 Are they difficult to reason with?

8.18 Is it difficult to get them to change activity?

8.19 Do they lose belongings?

8.20 Are they disorganised?

8.21 Does your child cope with change?

8.22 Is your child emotionally flat?

8.23 Does your child bang their head, pick or scratch their skin etc?

8.24 Do they rock back and forth?

8.25 Does your child have difficulty remembering more than one instruction?

8.26 Does your child have difficulty following instructions if they are shown what to do?

8.27 Is your child fearful of sounds?

Learning

9.1 Does your child confuse words, e.g. dog & god?

9.2 Does your child write well?

9.3 Does your child understand what they are reading?

9.4 Do you think they are behind their friends and peer group?

Additional information

10.1 Additional comments or information

10.2 Please tell us what you hope to gain from requesting this assessment?

Parental Information Form

Child and parents details

Data protection & GDPR

Current and proposed setting

Background

Birth history

Early history

Medical and health history

Play

Sensory

Eating

Behaviour

Learning

Additional information

Your Privacy

Child and
parents details

Data protection
& GDPR

Current and
proposed setting

Medical and
health history