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Background Form
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Background Form
Step 1 of 11
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Please read carefully.
Child Details
Date
*
Date Format: YYYY dash MM dash DD
Child's Full Name
*
First
Middle
Last
Date of birth
*
Date Format: YYYY dash MM dash DD
Gender
*
Male
Female
Age
*
Service Requested:
*
Counselling / Psychology
Education Support
Occupational Therapy
Physiotherapy
Speech/Language Therapy
Other
Other requested service
*
Mother's Details
Mother's Name
*
First
Last
Home Address
*
Street Address
Address Line 2
City
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Home Telephone
*
Work Telephone
*
Mobile Telephone
*
Email
*
Occupation
*
Father's Details
Father's Name
*
First
Last
Home Address
*
Street Address
Address Line 2
City
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Home Telephone
*
Work Telephone
*
Mobile Telephone
*
Email
*
Occupation
*
Referral Information
Who referred you to SPOT?
Please describe your child’s issues. Please include any information you feel is relevant:
*
Has your child been evaluated for any of the issues listed above? If so, by whom and when? What were the findings?
*
Birth and Infancy Details
Difficulties Following Birth:
Needed Oxygen
Needed Incubation
Had Trouble Sucking
Intubation
Other
Other difficulties following birth:
*
Difficulties During Infancy:
Sleeping
Irritable
Limp
Jittery
Rigid
Overactive
Colic
Under active
Other
Other difficulties during infancy:
*
Weeks Gestation
Weight
APGAR Score
Length of hospital stay
Child's Medical History
Ear Infections
Yes
Age
*
Frequency
*
Tonsillitis
Yes
Age
*
Frequency
*
Frequent Colds
Yes
Age
*
Frequency
*
Tubes in Ears
Yes
Age
*
Frequency
*
High Fever
Yes
Age
*
Frequency
*
Respiratory Infections
Yes
Age
*
Frequency
*
Allergies (please list all):
Seizures: (Frequency and when was most recent one?)
Please list and describe any significant injuries, illnesses or major operations along with the dates:
Has vision been examined?
*
Yes
No
Date
*
Date Format: MM slash DD slash YYYY
Results
*
Has hearing been examined?
*
Yes
No
Date
*
Date Format: MM slash DD slash YYYY
Results
*
Please list any medication your child is taking along with the reason it was prescribed:
Child's Developmental History
Please Note When Each Occurred. Please put N/A if not applicable:
Babbled:
*
Fed Self:
*
Sat:
*
Gestured:
*
Bladder Control:
*
Crawled:
*
Spoke first word:
*
Bowel Control:
*
Walked:
*
Put words together:
*
Dressed self:
*
Slept through the night:
*
Hand preference:
*
Right
Left
Swaps
Was your child bottle fed? Any problems?
Does your child have any problems with exaggerated gag reflex?
Did or does your child have any problems eating?
Child’s Educational Details
Name of pre-school:
*
Frequency:
*
Attended since:
*
Name of current school:
*
Frequency:
*
Attended since:
*
Please fill in Grade OR Year your child is in:
*
School System
*
IB (Year)
American (Grade)
Australian (Year)
Does your child receive additional support at school? If so, what type, how often and from whom?
*
Child’s Play and Behaviour Details
How well does your child play with other children/peers?
*
What are your child’s favourite play activities/ interests?
*
Please describe your child’s behavior/ mood at home:
*
Please describe your child’s behaviour at school:
*
Child’s Family History
Please enter the name and age of each sibling:
Siblings
Name
Age
Please list any other people living at home and their relationship to your child:
Name
Relationship
Please list all languages spoken at home:
*
What is your child’s native language?
*
Has anyone in the family ever had a history of any developmental, learning or mental health difficulties?
Additional Information
If your child requires therapy, what are your personal goals/expectations?
Please note any other information which you consider to be relevant:
Signature
Parent's Name Signing
*
First
Last
Signature
*
Please sign inside the box using either your mouse or finger on a touchscreen device.
Phone
This field is for validation purposes and should be left unchanged.