Parent's First Name

Parent's Last Name

Child's Name

What is your child date of birth?

Gender

Male

Female

1. What is your child's main difficulty or struggles in day to day activities?

2. Who in the family is involved in the child’s care and support?

3. Skills such as taking a first step, smiling for the first time, and waving “bye bye” are called developmental milestones- did your child meet the milestones at the expected range?

4. What interventions have you tried in your house? Did it work?

5. What play activities does your child take interest in? (Lego, sports, box games)

6. How much time does your child play outside the house (open air)?

7. How many hours does your child spend in-front of screens (TV, tablet, cell phone)

8 .What is your child’s sleep patterns/schedule?

9. Is your child ‘picky eater’? What does he/she eat?

10. What does your child's diet include - please give an example of a daily meal plan.

11. Is there a sibling? If so what is the relationship between the siblings?

12. Describe your child's strengths and weaknesses

13. Bowel habits (does your child suffer from constipation or diarrhea)?

14. Has your child develop any skin allergies such as eczema?

15. Does your child play with his peers? How does he communicate with them, does he feel isolated? Has he/she got any friends?

16. Does your child cope well with transitions? (Such as change of plans, stop one activity and start another)

Can you remember in the early stages of development if your child met the following milestones at the expected time range when?

Sitting / standing up

Turning over

Crawling – was the crawling synchronized?

walking by himself/herself before the age of 2 years old?

Toilet training

Language – Did your child use single words and sentences properly?

Did you experience setbacks and tantrums?

Did you experience head banging? – If so what was the trigger for this behavior?

Clumsy behavior -not synchronized in his/ her movements?

Was your child 'over sensitive' or 'under sensitive' to smell touch noises?

Additional information - Please tell me any relevant information about your child

What do you expect to achieve with my private coaching?

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