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Background Form

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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*

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Mother's Details
Mother's Name*
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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Father's Details
Father's Name*
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*
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:

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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
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.

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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.

Child's Full Name*
First Name Middle SURNAME
Chinese Name
Date of Birth*
Date Format: 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
- Discovery Bay
- No Preference
How did you find out about SPOT?*
- Website/Internet
- Facebook/Instagram
- Friend
- Teacher
- Doctor/Professional Referral
Which Doctor?
Facebook Live Code
I would like to receive information on parent courses, child groups and the monthly e-newsletter from SPOT
- Yes
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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

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