Psycho Educational Assessment | Parent Checklist

Childs Name *

First

Last

Respondent's Name *

First

Last

Respondent's Email *

Preferred Form of Address

Mr.
Mrs.
Ms.
Miss

Date: *

Part I: Current Home Status

A. With whom does the child live? *

B. Was the Child Adopted? *

C. Is/Was the child in foster care? *

D. Are any languages other than English spoken in the home? *

No
Yes, list languages

List primary language spoken: *

E. Does your child have any involvement with cultural activities and/or traditional languages? *

No
Yes, please specify

F. List the names, ages and relationship of other children living with the child: *

None

Please include the Name, Age and Relationship to the Child:

G. Have there been any recent changes in family life (for example, a move to a new home)? *

No
Yes (specify details)

H. Parent/Guardian *

First

Last

Child's Birth Father

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone

Birth Mother's Information *

First

Last

Address (If different from above)

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone

Are birth parents separated? *

Do parents share custody?

Is there a Step-father? *

Is there a Step-Mother? *

Part II: Birth History

A. What was the birth mother’s condition during pregnancy? *

Please Specify:

B. How would you describe the child’s birth? *

Please Specify:

Part III: Infancy and Early Childhood History

B. How would you rate the child’s early motor skills development, such as sitting up, crawling, and learning to walk? *

Additional Comment:

C. How would you rate the child’s early language development, such as first words, asking simple questions, and talking in sentences? *

Additional Comment:

D. During ages 3 through 5, how would you rate the child’s cognitive development, such as counting, knowledge of the alphabet, and general knowledge and understanding? *

Additional Comment:

E. During ages 3 through 5, how would you rate the child’s social development, such as ability to play with others, development of friendships, and relationships with adults? *

Additional Comment:

F. How difficult to manage was his or her behaviour during the preschool years? *

G. Did the child attend preschool (not daycare)? *

Additional Comment:

H. Did the child experience any traumatic events or major life changes during infancy and/or early childhood? *

No
Yes. (If yes please specify):

Part IV: Health Status

A. What is the child’s overall physical health? *

Is usually in good health and is physically fit
Is generally in good health
Other (specify):

B. Does your child have a health condition that does not require medication? *

No
Yes. If yes, specify health condition:

C. Does your child have a health condition that requires medication? *

No
Yes. If yes, specify health condition and medication:

D. Has the child ever sustained a head injury? *

No
Yes. If yes, provide details (nature of injury, date, etc.):

E. Has the child ever been unconscious? *

I don't know
No
Yes, for how long?

F. Has the child ever had a serious illness? *

No
Yes. If yes, provide details (e.g., date):

G. Was the child hospitalized? *

No
Yes. If yes, provide details (nature of illness, length of hospital stay):

H. Does the child have seizures? *

No
Yes. If yes, give date of onset and frequency of seizures:

I. Did the child have frequent ear infections (more than four within a twelve-month period)? *

J. How would you describe the child’s vision? *

If visual difficulties, please specify:

K. Has the child had a recent vision test? *

M. Has the child had a recent hearing test? *

Part V: Current Temperament and Mood

Part VI: Current Behaviours

Please base the ratings on the typical observations over the past year. Check one category for each item.

A. What is your child’s attitude toward school? *

Additional Comments:

B. How would you rate your child’s level of effort toward schoolwork? *

Additional Comments:

C. When helping or working at home, how attentive is your child to details? *

Additional Comments:

D. How would you rate your child’s attention span? *

Additional Comments:

E. How does your child typically respond to distractions? *

Additional Comments:

F. How would you rate your child’s response to tasks that are difficult for him or her? *

Additional Comments:

G. How would you rate your child’s level of organization? *

Additional Comments:

H. How well does your child maintain personal belongings? *

Additional Comments:

I. When given tasks to do, how often does your child remember to and follow through to complete the task? *

Additional Comments:

J. How would you rate your child’s follow-through on schoolwork? *

Additional Comments:

K. What is your child’s typical activity level when watching television, eating meals, or doing schoolwork? *

Additional Comments:

L. What is your child’s typical activity level in social situations outside of the home? *

Additional Comments:

M. What is your child’s style of motor activity? *

Additional Comments:

N. How would you rate your child’s listening ability? *

Additional Comments:

O. How much talking does your child do?

Additional Comments:

P. How would you describe your child’s responses to oral questions? *

Additional Comments:

Q. How good is your child at taking turns? *

Additional Comments:

R. How well does your child interact with peers? *

Additional Comments:

S. Describe your child’s friendships and peer relationships.

How many close friends does the child have?

Select all that apply:

The child sometimes feels picked on
The child is sometimes picked last
The child sometimes excludes other children
The child sometimes feels left out
The child sometimes picks on other children

Part VII: Challenging Behaviours in the Home

Check all that are a serious concern and negatively impact the child’s academic or social functioning.

A. Impulsiveness *

Other:

B. Overactivity *

C. Uncooperative behaviour *

D. Aggressiveness *

No
Yes. If yes, describe and/or check the behaviours that best describes your child:

E. Anxiousness *

F. Mood *

No (mood is usually happy or typical for age)
Yes. If yes, describe and/or check the behaviours that best describes your child:

G. Withdrawal *

No
Yes. If yes, describe and/or check the behaviours that best describes your child:

H. Inattentiveness *

No
Yes. If yes, describe and/or check the behaviours that best describes your child:

I. Other challenging and/or unusual behaviours *

No
Yes. If yes, please describe:

PART VIII: Positive Behaviours

J. Please list some of the child’s strengths and/or coping strategies:

Strengths:

Coping Strategies:

Contact SD46

Employment

Strategic Plan

Communications

Board of Education & Governance

Board Meeting Schedule

Policies, Bylaws & Regulations

Ensouling our Schools

Schools

School Hours

Inclusive Education

Technology

Online Registration

Bussing

Kindergarten

Forms

Early Years

Child Care

Nature-Based Learning

Indigenous Learning

Career Programs

International Education Programs

Child & Youth Mental Health HUB

Family & Community Engagement

DPAC

Communicating Student Learning

Active Travel

Psycho Educational Assessment | Parent Checklist