Educational Psychology Form -

EDUCATIONAL PSYCHOLOGY PRE-ASSESSMENT
QUESTIONNAIRE FOR PARENTS/CARERS:

This form includes payment conditions, parental / medical consent and a background referral form detailing information required by our Psychologist for the particular service that you require.

Please take your time to fill it all in, as the information is fundamental for our Psychologist to be aware of before meeting with your child.

**Please email copies of recent school reports or reports from other professionals that you think might be relevant for the assessment.**

Thank you very much

Educational Psychology Assessment Form

Newsletter

Step 1
Step 2
Step 3
Step 4
Step 5
Step 6
Step 7
Step 8

Child's name

Child's date of birth

Child's home address

Name of parent(s) / carer(s)

Who holds legal responsibility for the child

Are there any custody matters that we need to be aware of?

Parent / carer telephone number

Parent / carer email address

Name of child's school

Year group

Name of child's GP and Practice address

Has your child had an Educational Psychology Assessment carried out elsewhere within the last 6 months? If yes, please include the date of the assessment and where this was carried out

Who is requesting this assessment

What is the main reason for seeking the assessment? (It may help to list your main concerns briefly)

Has your child been assessed by any of the following professionals?

Speech and Language Therapist

Physiotherapist

Play Therapist/Child Counsellor

Occupational Therapist

Paediatrician

None of the above

Has your child been previously assessed by an Educational Psychologist? If ‘yes’ please give brief details (when, outcomes of assessment):

What do you hope will be achieved by this assessment?

Are there any special family circumstances that need to be considered, such as illness in the family, a recent bereavement, or parental separation/divorce? If ‘yes’ please give brief details

Are there members of the family or close relatives who may have reading or spelling difficulties or other learning difficulties? Please give brief details

How does your child communicate (e.g., speaks in full sentences, phrases, a few words, non-verbal communication)

Was there anything unusual during pregnancy or any difficulties during birth?

Is your child generally healthy?

Has your child had any serious injuries or illnesses that have required medical attention?

Does your child have any confirmed diagnoses or are awaiting any formal assessments?

Does your child take any regular medication? If ‘yes’ does this affect attention/concentration/memory in any way?

Does your child follow a specialised diet?

Have any of your child's skills been lost recently or deteriorated in any way? If ‘yes’ please give details.

Was your child late in developing language skills?

Is English the only language spoken at home? If ‘no’ please give details

Were there any delays in your child's gross motor skills development (crawling or walking)?

At present are your child's physical skills satisfactory? (walking, balance, motor-coordination, writing, drawing, finger manipulation)

Which hand does your child use for writing?

Has your child's vision and hearing been assessed recently? Please give approximate date of assessment:

Does your child wear prescribed spectacles/contact lenses or do they use coloured overlays?

Does your child complain of any visual-related difficulty, such as sensitivity to glare, migraines, eyestrain etc?

Do you think that your child is forgetful for his/her age?

Would you consider your child to have attention and concentration difficulties?

Is your child happy to go to school?

Would you consider your child to have friends at home and school?

Is your child coping at school?

Do you have any concerns regarding your child's behaviour in general?

Which subjects does your child do reasonably well in?

Has your child ever had extra teaching at school or home?

In what way is the school supporting your child with any concerns/difficulties?

Have any special allowances such as extra time, a reader for tests/exams ever been used in the past?

What are your child's current National Curriculum Levels or exam results if known (could add levels from end of school report) - English - Maths - Science

Will your child be sitting a school entrance exam in the near future?

Does your child regularly use a computer to submit work at school?

What are your child's interests and hobbies?

What are your child's strengths?

Does your child play a musical instrument or receive music tuition?

Do you give consent for us to contact your child's school to gain more information from them? Please write YES or NO

If you do give consent for us to contact your child's school, please can you share the school email address and the main class teacher's name. If you do not give consent, please write N/A

Please tick the boxes to show whether you give consent to the following:

I agree for my child to be seen for an Educational Psychology Assessment at The Children’s Wellness Centre

I understand I can withdraw my consent at any time, although withdrawal of consent will not necessarily be reflected in the fees due

I understand that the Educational Psychologist is unable to edit the results of the assessment or change observations included in the written report

I understand that photographs, audio and video may be used for assessment purposes and to monitor progress

I understand that if I am using the report for an appeal or Tribunal, I must consult my legal representatives first to ensure that a standard report will suffice. I am aware that the Psychologists are unable to attend Tribunals themselves and that the document is not written as a legal report

I understand that if I am using the report to share with the local authority it is my responsibility to check my local area will accept privately funded reports

I agree to the use of electronic communication. All documents will be password protected and saved as a PDF.

Due to the Educational Psychology Assessment being a drop-off session, please detail any allergies or medical conditions that we may need to be aware of whilst you are not on the premises of The Children’s Wellness Centre

Checkbox Field

I give full consent, in case of an emergency, for The Children’s Wellness Centre to authorize any medical treatment deemed necessary for my child, either on the premises of The Children’s Wellness Centre, or in a hospital

Please confirm your child's name

Terms and Conditions of Services within The Children’s Wellness Centre. By ticking the following checkbox, the client is accepting the statements and the terms and conditions below

Our Psychologists will adopt a client-led approach and will offer advice, support and options for next steps, but it is the client’s responsibility to decide what is right for their child

The Psychologist that you are seeing is DBS checked and holds Professional Indemnity insurance, practicing within the framework of their profession and registrations

The Psychologist reserves the right not to accept a referral, terminate an assessment or not to circulate an assessment report if the referral appears to be outside their area of expertise or the client fails to comply with the terms and conditions set out in this agreement

Any information shared by the client with the Psychologist and The Children's Wellness Centre is treated as confidential, unless a safeguarding concern is disclosed. Client details will not be passed onto other parties unless specifically requested e.g. forwarding reports to other professionals and schools

Payment for Educational Psychology assessments is required at the time of booking, in order to secure the space

Payment is usually made via BACS and clients will receive an email invoice once they have booked. Your assessment is confirmed on receipt of payment.

Unless there is an exceptional circumstance, due to high demand for services, we have a 10-day cancellation policy. Late cancellations and missed appointments, will still need to be charged in full

For any clients claiming through their health insurance, payment must be settled directly with The Children’s Wellness Centre by the client and may be able to be reclaimed via their insurance provider, using the receipt we can provide

Policies and full terms and conditions must be accessed via The Children's Wellness Centre website

If the client has a complaint against the Psychologist that they are seeing, they must inform The Children’s Wellness Centre, emailing jake@childrenswellnesscentre.co.uk immediately and all efforts will be made to resolve and settle any disputes, without litigation

EDUCATIONAL PSYCHOLOGY PRE-ASSESSMENT
QUESTIONNAIRE FOR PARENTS/CARERS:

Sign up to our newsletter for the latest news and events...

Ready to find out more?

Contact & Location

Follow Us

Quick Links

Our Charity Support

EDUCATIONAL PSYCHOLOGY PRE-ASSESSMENT QUESTIONNAIRE FOR PARENTS/CARERS:

Sign up to our newsletter for the latest news and events...

Ready to find out more?

Contact & Location

Follow Us

Quick Links

Our Charity Support

EDUCATIONAL PSYCHOLOGY PRE-ASSESSMENT
QUESTIONNAIRE FOR PARENTS/CARERS: