Child’s Name:

Date of Birth:
Current School attended & Year Group:
Home Address:
Person(s) with parental responsibility:
Parent / Guardian contact number and email:

1.0 SCHOOL HISTORY

Pre-School/Nursery Attended:
Primary School:
Post Primary School:

SCHOOL SUPPORTS (please indicate what supports the child has had, and for how long)

IEP

Withdrawal support (reason?)

SENCo Support

RISE NI

Educational Psychology

EA Supports e.g. Literacy Support,

Page 1
 Behaviour Advisory, Behaviour
Outreach, Autism Intervention, other
2.0 REASON FOR REFERRAL
Why have you requested this appointment? Please list your educational concerns and what you hope
to get from the assessment

3.0 FAMILY MAKEUP

Who does the child live at home with? Are there any learning difficulties diagnosed within the
immediate / wider family. Are there any neurodevelopmental disorder diagnosed within the family /
wider family (e.g. ASD / ADHD).

Page 2
4.0 MEDICAL HISTORY
Please comment on the following:
 Vision – Does your child wear glasses or suffer from any difficulties with their vision? When
was their last sight test?
 Hearing - Does your child experience any difficulties in regards to their hearing? When was
their last hearing test?
 General Health - Any allergies / medications / diagnoses
 Other professional involvement (current or historical) e.g. Speech and Language Therapy,
Occupational Therapy, Physiotherapy, Educational Psychology / Clinical Psychology /
CAMHS, Medical, Other

5.0 NEURODEVELOPMENTAL HISTORY

Please provide details and examples of each of the following:
 Pregnancy (Was your child born at full term / premature / late)?
 Please describe your pregnancy? Any illness/complications?
 Birth (Vaginal Delivery? C-Section? Breach? Forceps? Anoxia?) Any complications?
 Please described the bonding experience with your child?
 Please describe your child’s Early Days e.g. Settled / Unsettled
 Sleeping Patterns
 Feeding (breastfed / Bottle fed?)
 Any issues with feeding or transition to solids? E.g. did your child eat a wide and varied diet /
fussy eater etc

Page 3
6.0 DEVELOPMENTAL MILESTONES
Developmental Milestones. Did your child do any of the following, please note approximately when /
age

Wave Peekaboo
Reciprocate a smile Raise hands to be lifted
Crawl Walk
Babble Talk
Any concerns?

7.0 CURRENT DEVELOPMENT

 Speech and Language: Please note any concerns with use or understanding of speech. Does
your child understand jokes / sarcasm / idioms / expressions

Page 4
 Motor Development Please note any concerns with your child’s motor development (e.g.
handwriting, falling, clumsy, fine motor) Gross Motor: Can they ride a bike, use playground
equipment. Fine Motor: Can your child complete buttons, laces, zips

 Self Help and independence: Please provide information on the following areas: Ability to
work/play independently, Dressing, Washing and Self Care, Feeding/Eating, Organisational
Skills

 Attention and Concentration: Please note any concerns you have in relation to your child’s
attention and concentration e.g. hyperactive, daydreams, loses focus, squirms, fidgets etc)

Page 5
 Social Skills and Peer Relationships: Please comment on the following areas: Interaction with
peers – friends? Solve problems? Well liked? Any social difficulties? Ability to take turns/
share/ cooperate, Interaction with adults – understands boundaries/hierarchies, modulates
interactions to differ from peers, respectful/fearful.

 Emotional and Behavioural Development Please describe any emotional and behavioural
concerns, Self-esteem/ self-confidence, awareness of strengths and difficulties, Managing
feelings and emotions,

Page 6