Brief Initial Intake Form

If you are seeing us for the first time, please fill up this form.

Page 1 of 4

BIOGRAPHICAL INFORMATION

Surname*

Given Name*

Gender*

Male

Female

Birth Date*

Age*

Grade/Level

Birth Certificate Number/IC. No (Last 4 digits). *

School

Who does the child live with?

What languages are spoken in the home?

In which language is the child most competent?

If the child speaks more than one language, to whom does s(he) speak the different languages?

PARENTS

Mother

Age

Occupation

Father

Age

Occupation

Marital Status of Parents

Home Phone

Mother’s Mobile

Father’s Mobile

Preferred Email address*

Address

SIBLINGS

Sibling 1

Name

First

Last

Age

Sex

Living at home

Sibling 2

Name

First

Last

Age

Sex

Living at home

Sibling 3

Name

First

Last

Age

Sex

Living at home

Sibling 4

Name

First

Last

Age

Sex

Living at home

Sibling 5

Name

First

Last

Age

Sex

Living at home

Sibling 6

Name

First

Last

Age

Sex

Living at home

Other people living in the home:

Who is the primary care-giver?

What is the nature of the concern?

Have you contacted anyone else about this problem? If yes, kindly provide brief details (e.g. With who/ For what concern(s)? What has been done so far? Any follow-up from there?)

Any additional Information that you feel is pertinent to helping us understand the situation better (e.g. previous psychological assessment done, relevant developmental history, and relevant medical history):

Are you human?*

This field should be left blank