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背景资料表格

> 主页 » About Us » Forms » 背景资料表格

步驟 1 之 11

9%

请仔细阅读
儿童详细资料
今日日期*
年-月-日
全名*
名中間姓
出生日期*
年-月-日
性别*
- 男
- 女
年龄*
需要的服务*
- 心理咨询/临床心理学
- 学校支援
- 职业治疗
- 物理治疗
- 言语治疗
- 其他
Other requested service*

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Guardian 1 Details
Guardian 1 Name*
前綴名姓
Home Address*
地址（街道）地址（行 2）城市郵政編碼國家／地區
Home Telephone*
Work Telephone*
Mobile Telephone*
电邮*
Occupation*

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Guardian 2 Details
Guardian 2 Name*
前綴名姓
Home Address*
地址（街道）地址（行 2）城市郵政編碼國家／地區
Home Telephone*
Work Telephone*
Mobile Telephone*
电邮*
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
- 其他
Other difficulties following birth:*
Difficulties During Infancy:
- Sleeping
- Irritable
- Limp
- Jittery
- Rigid
- Overactive
- Colic
- Under active
- 其他
Other difficulties during infancy:*
Weeks Gestation
Weight
APGAR Score
Length of hospital stay

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Child's Medical History
Ear Infections
- 是的
年龄*
Frequency*
Tonsillitis
- 是的
年龄*
Frequency*
Frequent Colds
- 是的
年龄*
Frequency*
Tubes in Ears
- 是的
年龄*
Frequency*
High Fever
- 是的
年龄*
Frequency*
Respiratory Infections
- 是的
年龄*
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?*
- 是的
- No
今日日期*
月/日/年
Results*
Has hearing been examined?*
- 是的
- No
今日日期*
月/日/年
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
姓名年龄
Please list any other people living at home and their relationship to your child:
姓名关系
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*
名姓
Signature*
Please sign inside the box using either your mouse or finger on a touchscreen device.
Untitled
姓名
此欄位用作驗證填寫的資料是否正確，請勿修改。

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预约

请致电前台（852）2807 2992 或者填写问卷，稍后治疗师会电话与您联络

SPOT Central

17/F Wings Building
皇后大道中 110-116号
中环
Hong Kong

(852) 2807 3223

central@spot.com.hk

SPOT黄竹坑

10/F, 1021-25 One Island South
香叶道2号
黄竹坑
Hong Kong

(852) 2807 2992

contact@spot.com.hk

SPOT愉景湾

6/F, Flat 604
愉景湾广场南广场（A座）
Discovery Bay, Lantau Island
Hong Kong

(852) 2807 3223

central@spot.com.hk

SPOT Kowloon Bay

15/F, 1501A, Eastmark
常悦道21号
Kowloon Bay, Kowloon
Hong Kong

(852) 2807 0800

kowloon@spot.com.hk

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