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Please tells us about your child
Has your child been diagnosed or suspected of having a developmental disorder (Such as ADHD, Autism, Dyslexia). Please specify below:
Does your child struggle with the following? Please tick all appropriate boxes:
Anxiety (Such as fearful of going to school, parties, crowded places, being on their own in their room)
Emotional Regulation (Such as tantrums or aggressive outbursts, or struggles to display correct emotion)
Confidence and self esteem
Sensory Issues (Such as clothing uncomfortable, doesn’t like bright lights or loud places)
Concentration and Focus
Sitting Still (Such as always likes to fidget with thing... ’Ants in their pants’)
Co-ordination (Such as struggles with physical tasks, running throwing catching swimming, riding bike)
Poor muscle tone (Slumped with poor posture)
Eyesight (Such as wears glasses or struggle with squint or tracking issues)
Routine (Needs structure and rounine)
Sleep (Such as going to sleep, staying asleep, wetting the bed
Academic (Such as reading, writing, maths, memory or processing)
Any other important information or areas of concern
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Last Name
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Phone Number
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