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Background Form

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Child Details
Date*
YYYY dash MM dash DD
Child's Full Name*
First Middle Last
Date of birth*
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*

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Guardian 1 Details
Guardian 1 Name*
Prefix First Last
Home Address*
Street Address Address Line 2 City ZIP / Postal Code Country
Home Telephone*
Work Telephone*
Mobile Telephone*
Email*
Occupation*

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Guardian 2 Details
Guardian 2 Name*
Prefix First Last
Home Address*
Street Address Address Line 2 City ZIP / Postal Code Country
Home Telephone*
Work Telephone*
Mobile Telephone*
Email*
Occupation*

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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?*

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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

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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*
MM slash DD slash YYYY
Results*
Has hearing been examined?*
- Yes
- No
Date*
MM slash DD slash YYYY
Results*
Please list any medication your child is taking along with the reason it was prescribed:

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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?

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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?*

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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:*

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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?

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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
Guardian's Name Signing*
First Last
Signature*
Please sign inside the box using either your mouse or finger on a touchscreen device.
Untitled
Comments
This field is for validation purposes and should be left unchanged.

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Make an Appointment

Call and speak to our front of house staff on (852) 2807 2992 or fill in the quick enquiry form below and a therapist will call you back.

"*" indicates required fields

Child's Full Name*

First Name Middle SURNAME

Chinese Name

Date of Birth*

DD slash MM slash YYYY

Gender*

Male

Female

Name of School Attending

Primary Caregiver Name*

First Last

Relationship*

Phone number*

Email*

Note: Please use a unique email address. If a sibling is already using your email address, you can use the plus sign trick which works with most email providers as follows:
existingname+newsibling@mail.com

Service(s) requested:*

Speech & Language Therapy

Occupational Therapy

Physiotherapy

Clinical Psychology

Counselling

PsychEd / Education Assessments

DIRFloortime

Sensory Integration

Feeding Therapy

Unknown

Reason for referral/ what challenges is your child having?

Which location suits you best?*

One Island South - Wong Chuk Hang

Central

Kowloon Bay

Discovery Bay

No Preference

How did you find out about SPOT?*

Website/Internet

Facebook/Instagram

Friend

Teacher

Doctor/Professional Referral

Others

Which Doctor?

Facebook Live Code

I would like to receive information on parent courses, child groups and the monthly e-newsletter from SPOT

Yes

Comments

This field is for validation purposes and should be left unchanged.

SPOT Central

17/F Wings Building
110-116 Queens Road
Central
Hong Kong

(852) 2807 3223

SPOT South Island

1021-1025 One Island South
2 Heung Yip Road
Wong Chuk Hang
Hong Kong Island

(852) 2807 2992

SPOT Discovery Bay

Flat 604
South DB Plaza (Block A)
Discovery Bay
Lantau Island

(852) 2807 2992

SPOT Kowloon Bay

Unit 1501A, 15/F Eastmark
21 Sheung Yuet Road
Kowloon Bay
Kowloon

(852) 2807 0800

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