Please complete the form as fully as possible. All * questions must be completed.

Parent Name (completing this form) *
Child's Full Name *
Date of Birth *
Gender *
Was your child born prematurely? *
If yes, how many weeks premature was he/she?
Were there any difficulties at birth?
Explain *
Do you remember any problems your child had in infancy?
Eg: feeding difficulties, delay in walking, talking. *
Has your child had any previous difficulties with hearing? *

           

Does your child speak English as an additional language? (EAL) *


Which language other than English does your child speak?
Is your child bi lingual? *
Has your child had any previous difficulties with Speech and Language or does she/he jumble words, mispronounce sounds or have trouble remembering names for things? *
Does your child have any visual difficulties? *
For entry to Year 1 and above:
Did your child experience difficulty learning to read or write? *
Please add further information
Is there any history of family members with difficulties in learning to read and/or write? *
Does your child have difficulty with fine motor skills?
Holding a pencil, tracing, threading beads etc
Please add details. *
Does your child experience difficulties when demonstrating physical tasks involving coordination?
Climbing stairs, hopping, skipping etc
Please add details. *

Thank you for filling this in.

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