SBD Parent Questionnaire

Person completing the form:

Referral made by:

Reason/s for Referral:

At which age did the current problem begin?

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:

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

If yes provide details:

Sibling Information:
Name: Male/Female: Age: Grade: School: Biological/Step

Describe the child’s relationship with his/her sibling/s (where applicable)

Describe the child’s relationship with his/her parent/s or Guardian/s

Describe how the child relates with other adults (including family and friends)

Describe how the child relates to his/her peers

Describe the child’s sleeping pattern

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

If yes explain:

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

Developmental History
Were there delays in:

Walking YesNo
Crawling YesNo
Talking YesNo

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.
 
Name of School: Male/Female: Year: Grade: Grade/Group: Biological/Step

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? YesNo

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? YesNo

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? YesNo
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? YesNo

Parent/Guardian - Date