Child Pre Consultation Questionnaire

Please complete this questionnaire if you are an adult seeking consultation for a child in your care

1) Personal Details and Contact Information

Name of Child


Date of Birth (dd/mm/yyyy)


Gender
Male Female

Postal Address


Telephone Number



2) Registration with a General Practitioner

Who is your GP?


Postal Address


Telephone Number


I give consent for you to contact my GP

3) Tell me about the problem

Briefly describe the problem for which you are seeking consultation. You can write whatever you feel would help me understand your situation, but do try to end by summarising your top three concerns.


What do you hope the consultation will do or achieve, in relation to the concerns you have described above?


Have you tried anything else to improve matters?
Yes No

If so, please give some details


Are any other professionals involved in helping you with your child?
Yes No

If so, please give some details


4) Education

Does your child have any known difficulties with learning or development?
Yes No

If yes, please describe


Does your child attend mainstream school?
Yes No

Does your child require any extra support for learning or behavior in school?
Yes No

If yes, please describe


5) Friendships and Interests

How well does your child make and keep friendships?


Is there any history of being bullied or bullying others?
Yes No

What are your child’s interests and hobbies?


6) Child Health Background

Were there any problems that you know of, in the pregnancy and early development of your child?
Yes No

If yes, please describe


Does your child have any health problems (current or in the past)?
Yes No

If so has this involved any regular medication or treatment appointments (please outline)?


Does your child have any known mental health problems?
Yes No

If so has this involved any regular medication or treatment appointments (please outline)?


How well does your child sleep and eat?


How would you describe your child's mood and personality?


Has your child suffered any trauma, important change or loss which may be affecting him/her?
Yes No

If yes, please describe


7) Family Health Background

Do other members of the family have any current or previous health problems?
Yes No

If so has this involved any regular medication or treatment appointments (please outline)?


Do other members of the family have any current or previous mental health problems?
Yes No

If so has this involved any regular medication or treatment appointments (please outline)?


8) Home and Employment Situation

Briefly describe your home circumstances (e.g. Married or single? Who else lives at home? How happy are you where you live?)


Briefly describe the employment status for adults living at home, with details of the responsibilities and hours this involves.


9) General Information

Anything else you feel the consultant should know, that hasn’t already been asked about?


10) Payment Preferences

If consultations are arranged, I would like to pay for sessions in the following way
Credit Card
Sterling Cheque
Postal Order
Bank Transfer