Under 16s booking

This is a confidential pre- assessment form for children (Pre 16yrs) This is to be a completed by parent/carer prior to an assessment. Please do not complete this before you have been in contact to arrange an assessment.

Use a coloured overlay!

Child's full name Child's date of birth Age School year Country of birth Date moved to the UK (if applicable) Is the child adopted? What are the child's pronouns Title and full name of Parent/Carer requesting the assessment

Address

Country Address line 1 Address line 2 City/Town Postcode

Contact

Phone Email Do all those with legal responsibility for the child agree to this assessment?

Reasons for assessment

What are your concerns about your child? What views has your child expressed?

Health and development History

Did you experience any problems during the pregnancy or birth of your child? Were all the normal developmental milestones reached ?

e.g. walking, talking, riding a bike?

Has your child ever had any Speech and Language difficulties?

e.g. Understanding words, expressive language or pronounciation.

Is there a history of ear infections, glue ear or grommets? Is your child’s hearing within normal limits? Is your child on any regular medication that may be relevant?

Vision and Visual Difficulties

It is essential that the child has had a sight test within the last 2 years. If they have not, please make an appointment with an optometrist and return to this form when the eye test has been completed.

Has your child had any history of visual difficulties/problems with sight/visual impairment?

In some cases, difficulties with reading are caused by visual difficulties that are not related to learning. Therefore, if you have answered yes, you will need to discuss this with your Optician (Optometrist) prior to requesting an the assessment to see if an onward referral is required.

Does your child wear glasses? Has your child had a sight test within the last two years? Please give the date of the sight test Was any prescription made?

if yes, were they advised to use glasses/contacts for distance (e.g watching television) or near (e.g reading) or both?

Do they wear the prescribed glasses/ contact lenses as required? Has your child ever used coloured overlays or precision- tinted lenses?

If yes, please provide the following information

Who recommended and provided these? Why were they recommended? Did they help?, if yes in what way? Do you still use them? If not why not?

Visual difficulties

Please consider the following when completing the section below for their child. This section is designed to determine whether symptoms occur frequently. Therefore, if a symptom is experienced infrequently - such as rarely, occasionally, sometimes, or fewer than 2-3 times per month - please respond with ‘No.’

Do you often get headaches when you read or study?

Yes No

Do your eyes often feel sore, or gritty, or watery?

Yes No

Does reading from white paper or from a bright screen often feel uncomfortable?

Yes No

Does the print, or book, or screen, often appear blurred, or go in and out of focus when you are reading?

Yes No

Does the print, or book, or screen, often appear double, or go in and out of focus when you are reading?

Yes No

Do words often seem to move or merge together when you are reading?

Yes No

Do objects in the distance often appear more blurred after you have been reading?

Yes No

Do you often have to screw up your eyes to see more clearly when you are reading?

Yes No

Do you experience any other problems with your vision that interfere with your ability to read or study?

Yes No

If yes, then describe

In some cases, difficulties with reading are caused by visual difficulties that are not related to learning. Therefore, if you have answered yes, you will need to discuss this with your Optician (Optometrist prior to requesting an assessment to see if an onward referral is required.

Were the above highlighted visual difficulties discussed with the optician at the last eye test?

Yes No

Can you confirm that you are not awaiting a further referral regarding visual difficulties?

Yes No

Family History

Please indicate whether any other family members experienced difficulties with reading/writing /spelling/general learning or were ever diagnosed with a Specific Learning Difficulty.

Language and Linguistic History

To be assessed your child will need to have lived in an English speaking country and to have been regularly speaking english for a minimum of 7 years

If yes, please provide futher details including if English is the main or second language. Are there any difficulties in their first language?

Educational History

Did your child pass the Phonics Test?

If yes, At the end of year one or year two?

Has your child’s schooling been disrupted in any way?

Other than COVID-19 pandemic

COVID-19 Pandemic

If they were at school, how did they respond to smaller classes? if they were working online, how did they find it? Were they educated largley at school (i.e children of key workers) or at home?

At school

Have any of your child’s teachers discussed any difficulties your child is experiencing? Has your child seen any other specialists (e.g. Educational Psychologist, Advisory teacher etc)? Has your child received any support or intervention in the past?

Has your child received support for any of the following

Reading

1:1 in school Private tutor Small group Whole class

Maths

1:1 in school Private tutor Small group Whole class

Spelling

1:1 in school Private tutor Small group Whole class

Writing

1:1 in school Private tutor Small group Whole class

Current Situation

What is your child's current National Curriculum Levels (if appropriate)

English Maths

What are the difficulties currently in school?

Reading

Slight Moderate Severe

Spelling

Slight Moderate Severe

Maths

Slight Moderate Severe

Writing

Slight Moderate Severe

Sports and games

Slight Moderate Severe

Is there any specialist help currently given at school?

Please give details

Is your child currently receiving any tuition outside of school?

If yes, what support and how often?

Literacy

Please describe your child’s current strengths and difficulties with Literacy? Does your child have difficulty recalling the alphabet or other known sequences?

Numeracy

Please describe your child’s current strengths and difficulties with Numeracy? Does your child have difficulty telling the time?

Memory, Concentration and Attention

Does your child have difficulties with memory, attention or concentration?

Speech, Oral Language, Communication and Social Skills

Are there any current difficulties with speech, oral language or communication?

Organisational skills

Does your child have difficulties with social skills, behaviour, peer relationships or emotional adjustment? Does your child have difficulties with self-esteem and confidence?

Motor skills

Does your child have good organisation skills? Does your child have any difficulties with fine and gross motor skills e.g. body awareness, movement and balance? Does your child experience left/right confusion?

Strengths

Please provide information about the child’s strengths, what they are good at and what they enjoy doing

Please provide any other information that would be useful for the assessor to know and what you hope to get out of the assessment

Signed Relationship to child Date completed