Mindfulness Class Booking By Yvonne | December 14, 2014 Mindfulness Meditation & Relaxation Class Booking Form Parent Consultation - Pre Meeting Information Child's First Name* First Gender - please select*MaleFemaleChild's Age/Date of BirthParent 1 Name* First Parent 2 Name* First Parental Relationship Status - please select*MarriedSeparated/DivorcedCohabitingLiving SeparatelyWidowedFamily Composition: Inc siblings names and agesHousehold Composition: (Who lives at home currently, if different from above)Reasons for concern/referral for therapy (include duration of problems)Is there any link to recent life events or specific trigger you are aware of?Developmental History - any difficulties during pregnancy and delivery?Developmental History - any Postnatal depression or difficulties for parents during child's infancy?Developmental History - any concerns re developmental milestones?Developmental History - any health/medical issues for child, family or close relatives?Developmental History - describe child's personality as an infant and whether he/she was easy to manage and sootheDevelopmental History- describe any significant life events that have been difficult or beneficial for child and/or family membersChild’s current circumstances - any recent or upcoming major life changes?Child’s current circumstances - any significant family problems/issues or difficulties in parental relationship?Child’s current circumstances - any medical issues, medication or other therapies or assessments?Child’s current circumstances - how is child performing/engaging in school?Child’s current circumstances - how is child doing socially... significant friendships, relationships with peers etcChild’s current circumstances - describe relationships with parents, siblings or important extended family membersChild’s current circumstances - how is child's eating pattern/any issues?Child’s current circumstances - sleeping pattern/any concerns?Child’s current circumstances - emotional state/any concerns or worrying behaviours?Child’s current circumstances - sleeping pattern/any concerns?Child’s current circumstances - sleeping pattern/any concerns?Child’s current circumstances - strengths, talents and interestsChild’s current circumstances - difficulties and challengesFamily History (e.g. structure, dynamics, including extended family)Family History - medical & psychiatric (e.g. any history of depression, anxiety or other in child or parent's families)Family History - any addictions in immediate or extended family?Family History - any relevant family/personal historiesFamily History - describe parental relationship, and parenting styles (including any difference in or conflict in parenting styles)Does the family have a need for any additional supports?Any Other Relevant Information - recent significant events?Any Other Relevant Information - are any other services involved (current or past)Any Other Relevant Information - who is the child most attached to, who do they seek out if upset?Any Other Relevant Information - are there any other significant people in this child's lifeAny Other Relevant Information?For each item, please mark the box for Not True, Somewhat True or Certainly True. It would help us if you answered all items as best you can even if you are not absolutely certain or the item seems daft! Please give your answers on the basis of the child's behaviour over the last six months.Considerate of other people's feelingsNot TrueSomewhat TrueVery TrueRestless, overactive, cannot stay still for longNot TrueSomewhat TrueVery TrueOften complains of headaches, stomach-aches or sicknessNot TrueSomewhat TrueVery TrueShares readily with other children (treats, toys, pencils etc.)Not TrueSomewhat TrueVery TrueOften has temper tantrums or hot tempersNot TrueSomewhat TrueVery TrueRather solitary, tends to play aloneNot TrueSomewhat TrueVery TrueGenerally obedient, usually does what adults requestNot TrueSomewhat TrueVery TrueMany worries, often seems worriedNot TrueSomewhat TrueVery TrueHelpful if someone is hurt, upset or feeling illNot TrueSomewhat TrueVery TrueConstantly fidgeting or squirmingNot TrueSomewhat TrueVery TrueHas at least one good friendNot TrueSomewhat TrueVery TrueOften fights with other children or bullies themNot TrueSomewhat TrueVery TrueOften unhappy, down-hearted or tearfulNot TrueSomewhat TrueVery TrueGenerally liked by other childrenNot TrueSomewhat TrueVery TrueEasily distracted, concentration wandersNot TrueSomewhat TrueVery TrueNervous or clingy in new situations, easily loses confidenceNot TrueSomewhat TrueVery TrueKind to younger childrenNot TrueSomewhat TrueVery TrueOften lies or cheatsNot TrueSomewhat TrueVery TruePicked on or bullied by other childrenNot TrueSomewhat TrueVery TrueOften volunteers to help others (parents, teachers, other children)Not TrueSomewhat TrueVery TrueThinks things out before actingNot TrueSomewhat TrueVery TrueSteals from home, school or elsewhereNot TrueSomewhat TrueVery TrueGets on better with adults than with other childrenNot TrueSomewhat TrueVery TrueMany fears, easily scaredNot TrueSomewhat TrueVery TrueSees tasks through to the end, good attention spanNot TrueSomewhat TrueVery TrueOverall, do you think that your child has difficulties in one or more of the following areas: emotions, concentration, behaviour or being able to get on with other people?NoYes Minor DifficultiesYes Definite DifficultiesYes Severe DifficultiesIf you have answered "Yes", How long have these difficulties been present?Less than a month1-5 months6-12 monthsOver a YearIf you have answered "Yes", Do the difficulties upset or distress your child?Not at allOnly a littleQuite a lotA great dealIf you have answered "Yes", Do the difficulties interfere with your child's everyday life in the following areas?HOME LIFEFRIENDSHIPSCLASSROOM LEARNINGLEISURE ACTIVITIESDo the difficulties put a burden on you or the family as a whole?Not at allOnly a littleQuite a lotA great dealHow would you know things were better? What specific changes would you like to see?Form completed by (name/date) Posted in Uncategorized ← Reiki Energy Therapy
