Neuropsychology Assessment Form -

Neuropsychology Assessment Form

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Child's name

Child's date of birth

Name of parent(s) / carer(s)

Address

Telephone number

Name of school

Year group

Who is requesting this assessment (e.g., parents, child has asked for support, school have suggested it)

Has your child had an Educational Psychology Assessment or a Neuropsychology/Cognitive Assessment carried out elsewhere within the last 12 months? If yes, please include the date of the assessment and where this was carried out

Has your child ever been previously assessed by an Educational Psychologist or Neuropsychologist? If ‘yes’ please give brief details (when, outcomes of assessment):

What is the main reason for seeking the assessment? (It may help to list your main concerns briefly)

Has your child been assessed by any of the following professionals?

Speech and Language Therapist

Physiotherapist

Play Therapist/Child Counsellor

Occupational Therapist

Paediatrician

Psychologist

None of the above

What do you hope will be achieved by this assessment?

Are there any special family circumstances that need to be considered, such as illness in the family, a recent bereavement, or parental separation/divorce? If ‘yes’ please give brief details

Please briefly describe yours/your child’s mother’s pre-natal and developmental history.

Gestation period/how many weeks at delivery?

Labour length/ complications

Type (Vaginal/Caesarean)

Feeding/duration/type (i.e., breastmilk/ formula)

Appetite (e.g., any difficulties, fussiness, allergies?)

Sleeping issues (e.g., how was sleep and what age did your child sleep through?)

Current sleep (e.g., difficulties initiating/staying asleep)

Any further issues at pre-natal or peri-natal period with mother/baby

Please briefly describe your child’s social history:

Eye contact (past/present)

Facial expressions (past/present)

Imaginative play

Turn taking (ages 2-6)

Joining in play (ages 2–6)

Ability to initiate friendships (past/present)

Ability to maintain friendships (past/present)

Role in friendships (leader, follower, part of group)

Friends (e.g., mostly same age, older, younger)

Ability to understand jokes/sarcasm (does your child take things literally)

Ability to engage in social chit-chat

Please share information about your child's milestones. Please specify age where possible (year/month).

Did you notice any delays in your child's language development?

Yes

If yes, please specify:

Show interest in sound (by 3 months)

Yes

Please specify age (year/month).

Babbling (by 4 to 6 months)

Yes

Please specify age (year/month).

Understanding words (by 6-11 months)

Yes

Please specify age (year/month).

Speaking first words (by 12 months)

Yes

Please specify age (year/month).

Speaking in short phrases (by 24 months)

Yes

Please specify age (year/month).

Motor Development

Were there any delays noted in their motor development?

Yes

If yes, please specify:

Turn over (by 6 months)

Yes

Please specify age (year/month).

Sit alone (by 9-12 months)

Yes

Please specify age (year/month).

Crawl (by 9-12months)

Yes

Please specify age (year/month).

Stand alone (by 9-12 months)

Yes

Please specify age (year/month).

Walk alone (by 12-18 months)

Yes

Please specify age (year/month).

Walk upstairs (by 36 months)

Yes

Please specify age (year/month).

Walk downstairs (by 48 months)

Yes

Please specify age (year/month).

Running

Yes

Please specify age (year/month).

Which hand do they use for writing or drawing?

Right

Left

Which hand do they use for eating?

Right

Left

Which hand do they use for throwing?

Right

Left

At present are your child's physical skills satisfactory? (walking, balance, motor-coordination, writing, drawing, finger manipulation)

How old were they when they were first dry during the day for 12 hours without an accident?

Did bed-wetting occur after toilet training?

Yes

If yes, until what age?

Did bed-soiling occur after toilet training?

Yes

If yes, until what age?

Repetitive or compulsive Behaviours

Hair pulling

Skin picking

Knuckle Cracking

Scratching

Self-Injury

Other

None of the above

How does your child cope with change?

Please provide some family history/background (i.e., how many siblings, ages, family physical/mental health history)

Are there members of the family or close relatives who may have reading or spelling difficulties or other learning difficulties? Please give brief details

Is your child generally healthy?

Has your child had any serious injuries or illnesses that have required medical attention?

Does your child take any regular medication? If ‘yes’ does this affect attention/concentration/memory in any way?

Does your child follow a specialised diet?

Have any of your child's skills been lost recently or deteriorated in any way? If ‘yes’ please give details.

Is English the only language spoken at home? If ‘no’ please give details

Has your child's vision and hearing been assessed recently? Please give approximate date of assessment:

Does your child wear prescribed spectacles/contact lenses or do they use coloured overlays?

Does your child complain of any visual-related difficulty, such as sensitivity to glare, migraines, eyestrain etc?

Do you think that your child is forgetful for his/her age?

Would you consider your child to have attention and concentration difficulties?

Is your child happy to go to school?

Would you consider your child to have friends at home and school?

Is your child coping at school?

Do you have any concerns regarding your child's behaviour in general?

Does your child have a diagnosis of ADHD, autism or any learning needs?

Is there a history in the family of ADHD, autism or any learning needs?

Which subjects does your child do reasonably well in?

Has your child ever had extra teaching at school or home?

In what way is the school supporting your child with any concerns/difficulties?

Have any special allowances such as extra time, a reader for tests/exams ever been used in the past?

What are your child's current National Curriculum Levels or exam results if known (could add levels from end of school report) - English - Maths - Science

Will your child be sitting a school entrance exam in the near future?

Does your child regularly use a computer to submit work at school?

What are your child's interests and hobbies?

What are your child's strengths?

Does your child play a musical instrument or receive music tuition?

Do you give consent for us to contact your child's school to gain more information from them? Please write YES or NO

If you do give consent for us to contact your child's school, please can you share the school email address and the main class teacher's name. If you do not give consent, please write N/A

Are there any adjustments that need to be made for your child when performing the Neuropsychology Assessment?

Please tick the boxes to show whether you give consent to the following:

I agree for my child to be seen for a Neuropsychology Assessment at The Children’s Wellness Centre.

I understand I can withdraw my consent at any time, although withdrawal of consent may not necessarily be reflected in the fees.

I understand that the Psychologist is unable to edit the results of the assessment or change observations included in the written report.

I understand that photographs, audio and video may be used for assessment purposes and to monitor progress.

I understand that the Psychologist carrying out the Assessment is unable to complete any Tribunal work or attend Tribunals themselves

I agree to the use of electronic communication. All documents will be password protected and saved as a PDF.

I understand that the Psychologist may suggest an additional computer-based test (after the clinic assessment) if there are indications of inattentiveness or focus difficulties. This test incurs an additional £85 licence fee. It is not included in all assessments, as it is not always necessary. I understand that it is my choice whether or not to proceed with this test

Due to the Neuropsychology Assessment being an optional drop-off session, please detail any allergies or medical conditions that we may need to be aware of whilst you are not on the premises of The Children’s Wellness Centre

Checkbox Field

I give full consent, in case of an emergency, for The Children’s Wellness Centre to authorize any medical treatment deemed necessary for my child, either on the premises of The Children’s Wellness Centre, or in a hospital

Please confirm your child's name

Terms and Conditions of Therapeutic Services within The Children’s Wellness Centre. By ticking the following checkbox, the client is accepting the terms and conditions below

Our Psychologists will adopt a client-led approach and will offer advice, support and options for next steps, but it is the client’s responsibility to decide what is right for their child

The Psychologist that you are seeing is DBS checked and holds Professional Indemnity insurance, practicing within the framework of their profession and registrations

The Psychologist reserves the right not to accept a referral, terminate an assessment or not to circulate an assessment report if the referral appears to be outside their area of expertise or the client fails to comply with the terms and conditions set out in this agreement

Any information shared by the client with the Psychologist and The Children's Wellness Centre is treated as confidential, unless a safeguarding concern is disclosed. Client details will not be passed onto other parties unless specifically requested e.g. forwarding reports to other professionals and schools

Payment for Neuropsychology assessments is required at the time of booking, in order to secure the space

Payment is usually made via BACS and clients will receive an email invoice once they have booked. Your Assessment is confirmed on receipt of payment.

Due to extensive waiting lists, we have a 10-day cancellation policy. Late cancellations and missed appointments, will still need to be charged in full.

For any clients claiming through their health insurance, payment must be settled directly with The Children’s Wellness Centre by the client and can be reclaimed via their insurance provider, using the receipt we can provide

If the client has a complaint against the Psychologist that they are seeing, they must inform The Children’s Wellness Centre, emailing jake@childrenswellnesscentre.co.uk immediately and all efforts will be made to resolve and settle any disputes, without litigation

Neuropsychology Assessment Form

Motor Development

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