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SBD Parent Questionnaire

Learner’s Name

Learner's Date of Birth *

Name of person completing the form

Your name

Your email

Referral made by

Age of the learner

At which age did the current problem begin?

Reason/s for Referral:

What in your view, are the factors that caused, or are causing/or aggravating the problem?

What are current triggers?

FAMILY BACKGROUND

Please list everyone who lives in the home with the child:

Time away from home

Yes

Has the child lived away from home for any extended period of time?

If yes provide details:

SIBLING INFORMATION

Sibling 1

Name

Gender

Male

Female

Relation

Biological

Step

Age

Sibling 2

Name

Gender

Male

Female

Relation

Biological 1

Step

Age

Sibling 3

Name

Gender

Male

Female

Relation

Biological

Step

Age

Sibling 4

Name

Gender

Male

Female

Relation

Biological

Step

Age

Sibling 5

Name

Gender

Male

Female

Relation

Biological

Step

Age

Does the child have any habits that we should be aware of?

Yes

Does the child have any fears that we should be aware of?

Yes

If yes please explain:

How does the family spend free/leisure time/holidays together?

DEVELOPMENTAL HISTORY

Were there delays in:

Walking

Yes

Crawling

Yes

Talking

Yes

EDUCATIONAL HISTORY

Record of Schools Attended

Please indicate the names of all the schools that your child has attended including Pre-grade and Nursery schools.

School 1

Name of School

Year

Grade/Group

School 2

Name of School

Year

Grade/Group

School 3

Name of School

Year

Grade/Group

Name of Current School

Grade's Repeated

Medium of instruction

Is the medium of instruction in the current school the same as the child’s home language?

Yes

Comment on significant problems at school in the past and/or presently

Spelling/ Writing/ Reading/ Mathematics/ Behaviour/ etc.), and when it was first noted:

How does your child get to and back from school?

Who is with your child after school?

Who supervises your child’s homework?

Is your child able to concentrate for long periods/ is your child highly distractible?

Is there a family history of psychiatric illness?

Is there a family history of substance abuse?

Has the child been exposed to any substances?

Yes

STRENGTHS / INTERESTS

Please state the particular strengths and/or interests of your child

Sports, hobbies, clubs, reading, music, arts & crafts, etc.)

What are your expectations of us as a school?

Do you wish to apply for occupation in the hostel?

Yes

If yes, please complete the Hostel Application Form. (NB: exemptions do not apply to hostel fees)

Do you give permission for us to use photographs of your child on our website?

Yes

Parent/Guardian's Signature

You can sign the form right here

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