Tell Me About Your Child
If you are interested in learning more about
this programme, or feel that it might meet the needs of your child and
family, please fill in the following form, adding any further information
which you feel may be relevant and simply click the submit button, which
will return it to my e-mail address. If there are any questions you would
like answered, please include those and I will respond as quickly as I can.
Please fill out the following areas and press
the "submit" button:
Your Name:
Your Email Address:
Child's Name:
Date of Birth:
Home Address:
School (or any other relevant placement):
Diagnoses:
Age at which diagnoses were made:
Birth History:
At what age did your child begin to babble?
At what age did your child begin to use single
recognisable words?
At what age did your child begin to put words
together?
When did you become aware that your child was
different?
What was it that concerned you?
Does your child have any physical disabilities?
(If yes, please describe them)
Have your child's vision and hearing been
assessed? (If yes, what were the results?)
Is your child on any medication? (If yes, for
what condition and what is s/he taking?)
Does your child have a history of recurrent ear
infections? (If yes, when did they begin, how frequent have they been and
how have they been managed?)
Has your child had any operations? (If yes,what
for?)
Has your child had any significant illnesses or
accidents?
Is s/he accident-prone?
Yes
No
What types of therapy have you been involved
with so far?
Are you involved in any other teaching
programme? (if yes, which one?)
How much of what you say to her/him does s/he
understand?
How much of what s/he says to you do you
understand?
Do you have access to people who can help you
to carry out the programme?
Yes
No
Are you in touch with the families of other
children with similar difficulties to your child's?
Yes
No
(It can be beneficial
all round if there are a few families interested in starting a programme
such as this at the same time, in terms of training, group support and the
sharing of resources and helpers).
