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The Gifted Lab - Child Questionnaire
Purpose of the Questionnaire
This questionnaire is designed to help the psychologist gain a better understanding of your child, including their developmental background, strengths, and areas of concern from the perspective of parents/guardians.
Please complete the questionnaire as accurately and thoroughly as possible, based on your knowledge and observations of your child.
Please note that the information provided in Sections A to E may be incorporated into your child's final psychological assessment report.
If a question is not applicable, you may indicate "N/A".
Thank you for taking the time to provide this important information. Your input will help us better understand your child's needs and provide appropriate recommendations.
A. General Information
Child's Full Name (as in Birth Cert / Passport)
*
Child's Birth cert No / NRIC No:
(Please bring along your child's BC/IC for your appointment for verification)
*
Nationality
Gender
Please select
Female
Male
Date of Birth
*
DD
/
MM
/
YYYY
School
Class / Level
Main Language/s used at home
Mother's Name
*
Mother's Contact No.
*
Mother's Email
*
Father's name
*
Father's Contact No.
*
Father's Email
*
People, other than the parent(s) and child, living in home
Name / Age / Relation to child
Who are the main people who look (looked) after the child on a day-to-day basis?
Name of person / Relation to child / Period of time
B. Parent's / Guardian's Concerns
1. What is the main purpose of this referral and your current concerns?
*
2. Indicate the psychologist that you have chosen for your child's assessment/consultation:
*
Dr Wilson Chan
Ms Deborah Ho
NA
3. Appointment Date & Time with The Gifted Lab (Please indicate in the box below)
*
Assessments required (Please tick)
To obtain an idea of my child's intellectual potential, providing an outline of his or her cognitive strengths and weaknesses.
*
IQ/Cognitive/Gifted Assessment
Not applicable
4. Do you need this psychological assessment report for application of exam access arrangements (AA)?
*
Yes - Tick Learning Difficulties Assessment
No
Not applicable
Suspected dyslexia, dysgraphia, dyscalculia, etc. Child has difficulty in math and/or reading, writing and/or spelling, weakness in language development, memory and sequencing)
*
Learning Difficulties Assessment with consultation (Inclusive of IQ/Cognitive Test)
Not Applicable
Academic Achievement Assessment - An evaluation of your child's academic attainment level.
Comprehensive Academic Achievement Assessment with consultation (Inclusive of IQ/Cognitive Test)- (from 6 years old / Kindergarten to 18 years / Grade 12 age-equivalent)
Not Applicable
5. Do you need a full diagnostic assessment for Attention Deficit Hyperactivity Disorder (ADHD)?
*
Yes - Tick Full Attention Assessment
No
Not applicable
Add-on assessment: To help understand your child’s attention (ADHD/ADD) and executive functioning.
Attention Screener - (age 4 yrs and above)
Full Attention Assessment (includes 1 questionnaire for parents, 1 questionnaire for school and attention screener for child. Additional questionnaire will be chargeable) - (age 4 yrs and above)
Not Applicable
Add-on assessment: To help understand your child’s socio-emotional / behavioural / EQ functioning.
*
Autism Screener - Helps in identifying autism and estimating its severity in children from the age of 3 (1 questionnaire for parents)
Emotional Quotient (EQ) Screener - Assess the EQ level of children (age 7 years as of birth date to 18 years)
Socio-emotional Screener - Assess for the risk of socio-emotional issues affecting young children from age 2 to 5 (includes 1 questionnaire for parents, 1 questionnaire for school)
Socio-emotional/Behavioural Assessment - Assess for the risk of socio-emotional/behavioural issues affecting children from the age of 6 to 10 (1 questionnaire for parents, 1 questionnaire for school. Additional questionnaire will be chargeable)
Socio-emotional/Behavioural Assessment - Assess for the risk of socio-emotional/behavioural issues affecting children/youth from the age of 11 (1 questionnaire for parents, 1 questionnaire for school, 1 questionnaire for child/youth)
Not Applicable
Add-on assessment: To obtain a profile of your child's reading, spelling, mathematics and personality.
*
Reading Screener - Assess current reading level (age 5 years to 7 years as of birth date)
Spelling Screener - Assess current spelling level (age 5 years to 7 years as of birth date)
Mathematics Screener - Assess current mathematical level (age 5 years to 7 years as of birth date)
Personality Career Screener - Assess an individual's personality strengths and potential fields of studies or work careers (age 14 to 18 years)
Not Applicable
Others (Please indicate in the box below)
Has your child taken any psychological tests/assessments before? Please note that prior exposure (within the last 12 months) to test materials invalidates results.
*
No
Yes
If yes, please provide the name of the tests and the name of the professional / clinic / centre who conducted it.
*
C. Health History
1. Please state length of pregnancy and the birth procedures (e.g. Normal, breech, caesarean, forceps)
Length of Pregnancy
Birth Procedure
2. Were there any problems that you and/or your child had during the pregnancy or immediately following birth?
Please select
Yes
No
If yes, please describe (E.g. Diabetes, jaundice, breathing problems, need of incubation, bruises, abnormalities, sucking or swallowing difficulties, etc.)
3. At what age did the following occur?
Sit alone
Walk alone
First words
Use 2 word sentences
Day time bladder trained
Night time bladder trained
Bowel trained
Tie shoelaces
4. Has your child had any major diseases and/or illness? (Please check)
Colic
Measles
Earaches
Chicken Pox
Scarlet fever
Pneumonia
Tonsillitis
Whooping cough
Convulsions or seizures
Head injuries
Meningitis or encephalitis
Allegies
High Fever
Asthma
None
Other
5. Any existing diagnosis? (state diagnosis and name = designation + organisation of professional who made diagnosis + date of diagnosis)
6. Did your child have any major accidents? Was he/she ever hospitalised? If so, at what age, for what reason and for how long?
D. Educational History
1. Is your child receiving any form of academic support in pre-school / school?
Yes
No
If yes, please give details
2. Has your child undergone any IQ test or any other assessment (Speech, Occupational Therapy, Psychological, Educational, etc) before?
Yes
No
If yes, please give details
3. Is your child receiving any other forms of therapy or intervention support?
Yes
No
If yes, please give details
4. Is your child attending any extra enrichment classes outside pre-school / school? E.g. tuition, Kumon, student care centre, music, art, ballet, etc.
Yes
No
If yes, please give details
5. Please indicate the pre-school / kindergarten / schools your child has attended.
School / Level / No. of years / Feedback from teachers
School / Level / No. of years / Feedback from teachers
School / Level / No. of years / Feedback from teachers
School / Level / No. of years / Feedback from teachers
6. Briefly describe your child's progress in each area: e.g. How difficult was it for your child to learn to read/ spell...?)
English Oral
English Reading
English Spelling
English Writing
Maths
Science (if applicable)
Mother Tongue (please specify, e.g. Chinese, Malay, Tamil, etc)
Work habits (E.g. ability to sustain attention, organisation, distractibility)
Special interests and abilities
7. Please forward school academic results, previous psychological reports, medical reports, sample of school work, etc (if applicable) to the following email address:-
thegiftedlab@gmail.com
E. Adjustment
1. Does your child have problems with any of the following?
Temper tantrums
Aggressive fighting
Destructiveness
Fire setting
Rivalry,unwillingness to share
Shyness
Unusual fears
Sexual difficulties
Delayed speech or stuttering
Lying
Stealing
Thumb sucking
Bedwetting,Daywetting
Bowel soiling
Muscle tics or twitching
Breath holding spells
Hyperactivity
Sadness
Inability to concentrate
Fear of being left alone
Nightmares
Tends to give up easily
Cruelty to younger children or animals
If yes, please give details
2. How does your child get along with siblings (if applicable)?
3. To what extent does your child get along with siblings (if applicable)?
Worst
1
2
3
4
5
Best
4. How does your child get along with other children?
5. To what extent does your child get along with other children?
Worst
1
2
3
4
5
Best
6. How does your child get along with teachers?
7. To what extent does your child get along with teachers?
Worst
1
2
3
4
5
Best
8. Are there any major stresses your child has experienced? (e.g. death in the family, illness, divorce, etc)
1. Has any of your other children (if applicable) been previously assessed at Gifted Academy / The Gifted Lab? If yes, please indicate name.
2. How did you get to know about our services?
Please indicate your preference if you would like to receive marketing materials and information relating to services and/or products offered by The Gifted Lab.
Yes
No
Please note:
* Fees paid are non-refundable or transferable and to be paid before consultation.
* Confidentiality of all clients will be strictly observed.
* The psychological assessment report will normally be ready within 3 weeks from last assessment date.
* Only the final psychological assessment report will be released to the parent/guardians.
* Request for additional copies of psychological assessment report are chargeable accordingly.
* Prices will vary depending on the type/number of areas for investigation and/or preference of the psychologist.
This form is completed by (Relationship to child)
*
Privacy & Disclaimer
Your personal information collected will be treated in the strictest confidence and will not be disclosed to any other party.
