Intake form - Educational assessments with Dayne WilliamsPlease 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/privacypolicyPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Medical aid detailsPrincipal member Name *FirstLastMedical aid: *Membership number: *Dependent code of child *0001020304Details of childName *FirstLastDate 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 problemHas your child been assessed previously? If yes, please specify *Attach previous assessment(s) (This is optional but strongly encouraged) Drag & Drop Files, Choose Files to Upload You can upload up to 4 files. Please attach latest school report (or more if available) * Drag & Drop Files, Choose Files to Upload You can upload up to 4 files. Details of MotherName of Mother/Guardian *FirstLastWorking hours *Occupation *AgeHome language *Marital status *MarriedNever marriedWidowDivorcedEstrangedLiving togetherEmail *Phone *Details of FatherName of Father/Guardian *FirstLastWorking hours *Occupation *Age Home language *Marital status *MarriedNever marriedWidowDivorcedEstrangedLiving togetherEmail *Phone *Home detailsIf divorced, who has legal custody of your childNot ApplicablemotherfatherAre there step-parent(s) involved? *yesnoN/AIf yes, when was the remarriage for either parent? Step-Parent(s) or Legal Guardian(s) Names: FirstLastNameFirstLastHome 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 historyPlease 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 functioningHow would you rate your child's performance, according to ability? *BelowAboveAs expectedHow does your child feel about his/her scholastic progress? *SatisfiedWorriedindifferentDoes your child’s performance vary from day to day? *yesnoHas there ever been a sudden change in performance? *yesnoHas your child ever repeated a school year? If yes please indicate Grade *What is your child's attitude towards school? *EnthusiasticIndifferentWould prefer not to goHas 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 classroomIt is generally best to provide their current teacher as they have recently observed them. Physical developmentDescribe any problems related to the pregnancy: *Normal pregnancyAccidentsInjuriessigns of miscarriageGerman MeaslesHigh blood pressureLow blood pressureX-ray treatmentKidney problemsHigh alcohol intakeother (optional)Was the pregnancy planned?yesnoDuration of pregnancy: *NormalPremature (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? *NormalSoonerLaterWere motor milestones reached within the suggested age range? *NormalSoonerLaterComments regarding to developmental milestones (optional)Control over big movements, e.g. running *ClumsyAverageGoodControl over small movements, e.g. threading beads/writing *ClumsyAverageGoodDid the teacher at your child’s preschool identify any problems? Please indicate any problems related to sensory development: VisionPlease indicate any problems related to sensory development: HearingWas your child examined and treated for any problems related to these developmental areas? Has your child had all the prescribed immunisations? *YesNoHas 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? *ConvulsionsFitsBlack-outsCerebral concussionHabit of banging headN/AMedical historyPlease provide information on any medication your child is taking at present: *DosePeriod usedreason for prescriptionDoes 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? *WellModeratelyPoorPlease elaborate on social concerns (if any)Does your child talk freely with their mother/father about their problems? *WellModeratelyPoorHow would you rate your child’s intellectual ability? *SuperiorAbove averageAverageBelow averageIs your child currently seeing an academic tutor? (If yes please state for which subject)How would you rate your child’s short term memory? *SuperiorAbove averageAverageBelow averageHow 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? YesNoDoes he/she write down his homework on a regular basis? YesNoDoes he/she often forget the nature of homework instructions? YesNoDoes he/she forget books at home or at school? YesNoThird ChoiceIs there a lot of disagreement during homework time? YesNoThird ChoiceDoes it happen that your child knows his/her homework at home, but not in school? YesNoIs her/his school bag untidy and disorganized or neat? UntidyDisorganizedNeatDoes it often happen that class work has not been completed?YesNoThird ChoiceDoes your child experience problems with his/her study methods?Planning of study programmeSummarizing the workMemorizingDoes not start studying in timeDoes not know how to studyCannot concentrate on the workQuestionnaire completed by *FirstLastDate *Submit
