Consent form educational assessment -Shannon |

Intake and consent form - Educational assessments with Shannon Willows (May)

Please fill out the following form to assist the assessment process. NB: All information submitted via this form is strictly confidential and stored securely. Please read our privacy policy for more information about how your information is used and stored at www.daynewilliams.co.za/privacypolicy

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- Step 1 of 2

Medical aid details

Principal member Name *

First

Last

Medical aid: *

Membership number: *

Dependent code of child *

Details of child

Name *

First

Last

Date of birth *

Cell number *

Home Language *

History of current problem/what are your current concerns regarding your child *

At what age was the problem first noted?

Please describe any illness or injury that may have been associated with the problem

Has your child been assessed previously? If yes, please specify *

Attach previous assessment(s) (This is optional but strongly encouraged)

Click or drag files to this area to upload. You can upload up to 4 files.

Please attach latest school report (or more if available) *

Click or drag files to this area to upload. You can upload up to 4 files.

Details of Mother

Name of Mother/Guardian *

First

Last

Working hours *

Occupation *

Age

Home language *

Marital status *

Email *

Phone *

Details of Father

Name of Father/Guardian *

First

Last

Working hours *

Occupation *

Age

Home language *

Marital status *

Email *

Phone *

Home details

If divorced, who has legal custody of your child

Are there step-parent(s) involved? *

If yes, when was the remarriage for either parent?

Step-Parent(s) or Legal Guardian(s) Names:

First

Last

Name

First

Last

Home address *

If your child has any siblings please indicate their names and ages below, as well as how they get on with the child being assessed. In case of only child please indicate this below. *

School history

Please indicate where you child attended Grade R and primary school and during which years. *

Please indicate where your child attended high school and during which years. *

Current scholastic functioning

How would you rate your child's performance, according to ability? *

Below
Above
As expected

How does your child feel about his/her scholastic progress? *

Satisfied
Worried
indifferent

Does your child’s performance vary from day to day? *

Has there ever been a sudden change in performance? *

Has your child ever repeated a school year? If yes please indicate Grade *

What is your child's attitude towards school? *

Enthusiastic
Indifferent
Would prefer not to go

Has your child's attitude changed for any reason? If yes, please elaborate:

Please indicate any extra-mural activities (in or out of school): *

Please provide the name and email address of the teacher who your son/daughter feels knows them best in the classroom

It is generally best to provide their current teacher as they have recently observed them.

Physical development

Describe any problems related to the pregnancy: *

Normal pregnancy
Accidents
Injuries
signs of miscarriage
German Measles
High blood pressure
Low blood pressure
X-ray treatment
Kidney problems
High alcohol intake

other (optional)

Was the pregnancy planned?

Duration of pregnancy: *

Normal
Premature (36 weeks or less)
Postmature (41 weeks or more)

Age of mother at birth: *

Describe any problems related to the birth:

Apgar score:

Birth weight:

Describe any feeding problems during infancy:

Were language milestones reached within the suggested age range? *

Normal
Sooner
Later

Were motor milestones reached within the suggested age range? *

Normal
Sooner
Later

Comments regarding to developmental milestones (optional)

Control over big movements, e.g. running *

Clumsy
Average
Good

Control over small movements, e.g. threading beads/writing *

Clumsy
Average
Good

Did the teacher at your child’s preschool identify any problems?

Please indicate any problems related to sensory development: Vision

Please indicate any problems related to sensory development: Hearing

Was your child examined and treated for any problems related to these developmental areas?

Has your child had all the prescribed immunisations? *

Has your child been hospitalised for any illnesses? If so, please specify age and duration:

Specify any traumatic injuries and/or operations along with age at particular time:

Has your child ever experienced any of the following? *

Convulsions
Fits
Black-outs
Cerebral concussion
Habit of banging head
N/A

Medical history

Please provide information on any medication your child is taking at present: *

Dose

Period used

reason for prescription

Does any other member of your family suffer from a serious chronic illness? If so please decribe:

Please specify if any member of your family is neurodiverse (e.g ADHD/Autism Spectrum) or suffers from any psychiatric conditions (E.g. depression/anxiety/eating disorders)

Just a reminder that is strictly confidential.

List your child’s strengths. *

Briefly describe any past or present emotional difficulties (e.g. frequent nightmares, detached affect): *

Briefly describe any past or present behavioural difficulties (e.g. frequent nightmares, detached affect): *

How would you describe your child’s temperament/personality? *

How does your child get on with friends? *

Well
Moderately
Poor

Please elaborate on social concerns (if any)

Does your child talk freely with their mother/father about their problems? *

Well
Moderately
Poor

How would you rate your child’s intellectual ability? *

Superior
Above average
Average
Below average

Is your child currently seeing an academic tutor? (If yes please state for which subject)

How would you rate your child’s short term memory? *

Superior
Above average
Average
Below average

How would you describe your child’s ability to sustain attention and concentration? *

Please detail any particular current learning difficulties:

Please detail any behavioural difficulties at school:

Is there any history of family struggling with learning difficulties at school? *

Does your child often need help with homework?

Does he/she write down his homework on a regular basis?

Does he/she often forget the nature of homework instructions?

Does he/she forget books at home or at school?

Is there a lot of disagreement during homework time?

Does it happen that your child knows his/her homework at home, but not in school?

Is her/his school bag untidy and disorganized or neat?

Untidy
Disorganized
Neat

Does it often happen that class work has not been completed?

Does your child experience problems with his/her study methods?

Planning of study programme
Summarizing the work
Memorizing
Does not start studying in time
Does not know how to study
Cannot concentrate on the work

Questionnaire completed by *

First

Last

Date *

I/We *

Single Line Text *

Give permission that (my/our child/person under my care) *

is assessed by Shannon Willows (May) at Harfield Practice for a Psycho-Educational Assessment on *

1. Acknowledge that the information collected by means of psychological tests is only meaningful if it is interpreted by somebody who knows the theory which underlies the relevant test and interprets it in the context of the situation.

2. Acknowledge that the limitations of the specific tests will be explained to me when required.

3. Provide consent that my/our child’s teachers may be contacted and classroom observations conducted in order to gather additional information to guide the assessment process and provide additional insight about his functioning at school.

4. Give consent to communicate information and reports (where applicable) via email and/or Whatsapp messaging platform.

5. Provide consent that the results and recommendations of my/our child's assessment may be communicated to the following parties, in order to fully support him or her in the classroom - These may include relevant professionals (eg occupational therapists, psychiatrists etc.) or your child's school-based support team/teacher/grade head

6. Acknowledge that I/we gave my/our consent, willingly and without being unduly influenced to do so by my/our therapist or any other person.

Please note that all private information collected about you and/ your child will be treated as highly confidential; no information will be disclosed without your consent, unless we feel your child is at harm to themselves, others or if required to do so by a court of Law.

Signature of mother/guardian *

Please use mouse (pc) or finger (phone/tablet) to sign above

Signature of father/guardian *

Please use mouse (pc) or finger (phone/tablet) to sign above

Signature of child/adolescent *

Please use mouse (pc) or finger (phone/tablet) to sign above

Payment instructions

Please note that Dayne Williams & Associates operate as a cash practice and therefore the patient/parent is responsible for payment. Once payment has been made you will be issued with a receipt which can be used to claim back from medical aid. Please consult your medical aid first to ensure psychological sessions are covered in full.

Payment must be made on or before the day of assessment with a POP sent to nicky@daynewilliams.co.za. No assessments can commence without this. Please find banking details below

Bank Details

Account Holder: D Williams & Associates

Bank Name: FNB

Branch Number: 050655

Account Number: 63117157156

Please use name and surname as a reference

Date *