Neurodevelopmental assessment questions

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Pupil's name(Required)

First Last

Pupil's Date of birth(Required)

DD slash MM slash YYYY

School name and address(Required)

Street Address Address Line 2 City Postcode

Gender(Required)

Male

Female

Name of person completing form(Required)

First Last

Phone(Required)

Email(Required)

Relationship to child/ how long known the pupil:(Required)

Name and contact details of SENCO:(Required)

Has the pupil been assessed by an educational psychologist?(Required)

Yes

If yes, please attach report or outline outcome of assessment.

Max. file size: 10 MB.

What is the pupil’s current educational level (Yr of schooling)?(Required)

Is the school mainstream?(Required)

Yes

Does the pupil have special educational needs?(Required)

Yes

If yes, please detail

Does the pupil receive extra support or help at school (Speech and Language/ Occupational therapy/ Counselling)?(Required)

Yes

If yes, please detail

Does the pupil have any disabilities (visual, hearing, physical, medical)?(Required)

Yes

If yes, please detail

Has the pupil ever been suspended or excluded from school?(Required)

Yes

If yes, please detail

Has the pupil ever failed or repeated a subject class or year?(Required)

Yes

If yes, please detail

Does the pupil have friends?(Required)

Yes

If yes, please detail. Please indicate if the pupil has a best friend and number of friends and what they enjoy doing together. If the pupil does not have friends, can you give an indication as to why. Are they part of a group or on the periphery? Do they fall out with peers easily, hold grudges? Able to have reciprocal conversations or are conversations one-sided on specific topics? Do they have a strong sense of right and wrong?

Are there or have there ever been any safeguarding concerns?(Required)

Yes

If yes, please detail

What is the pupil’s attendance? Please outline reasons for absences(Required)

What are the primary concerns for this Child? Please list 3 concerns(Required)

Please comment on the following areas - Academic performance/ General approach to learning, Temperament/ Personality, Current emotional state (Pupil’s predominant mood? Does it fluctuate? Outbursts? Clear triggers?)(Required)

The following questions look at symptoms of inattention. If you answer yes to a question, please think of an example and how it causes impairment at school. Does the pupil often make careless errors e.g. rushing work, missing out questions, not checking questions on opposite side of paper in tests, finding tasks that require a lot of attention to detail particularly stressful or time consuming?(Required)

Yes

If yes, please detail

Does the pupil often fail to sustain attention in tasks or play e.g. finding tasks that require sustained attention notably more difficult than peers?(Required)

Yes

If yes, please detail

Does the pupil often appear not to listen to what is being said to him or her?(Required)

Yes

If yes, please detail

Does the pupil often fail to follow through on instructions or finish tasks?(Required)

Yes

If yes, please detail

Does the pupil often struggle in organising tasks and activities e.g. miss deadlines, be late, leave things at home?(Required)

Yes

If yes, please detail

Does the pupil often avoid or strongly dislike tasks that require sustained mental effort?(Required)

Yes

If yes, please detail

Does the pupil often lose things?(Required)

Yes

If yes, please detail

Does the pupil often appear easily distracted by external stimuli?(Required)

Yes

If yes, please detail

Does the pupil often appear forgetful in daily activities?(Required)

Yes

If yes, please detail

The following questions look at symptoms of hyperactivity. If you answer yes to a question, please think of an example and how it causes impairment at school. Does the pupil often fidget with their hands or feet and squirm in their chair?(Required)

Yes

If yes, please detail

Does the pupil often leave their seat in situations in which remaining seated is expected?(Required)

Yes

If yes, please detail

Does the pupil often run about or climb excessively in situations in which it is inappropriate?(Required)

Yes

If yes, please detail

Does the pupil often appear unduly noisy in playing or have difficulty engaging quietly in leisure activities?(Required)

Yes

If yes, please detail

Does the pupil often exhibit a persistent pattern of excessive motor activity that is not modified by context?(Required)

Yes

If yes, please detail

The following questions look at symptoms of impulsivity. If you answer yes to a question, please think of an example and how it causes impairment at school. Does the pupil often blurt out answers before questions have been completed?(Required)

Yes

If yes, please detail

Does the pupil often fail to wait in lines or wait turns in games or group situations?(Required)

Yes

If yes, please detail

Does the pupil often interrupt or intrude on others?(Required)

Yes

If yes, please detail

Does the pupil often talk excessively without appropriate response to social constraints?(Required)

Yes

If yes, please detail

Other potential issues. Does the pupil have any generalised learning difficulties or specific difficulties such as reading, writing or arithmetric difficulties?(Required)

Yes

If yes, please detail

Does the pupil have any difficulties with speech and language?(Required)

Yes

If yes, please detail

Does the pupil have any motor or vocal tics?(Required)

Yes

If yes, please detail

Does the pupil have difficulty complying with authority?(Required)

Yes

If yes, please detail

Please outline any issues that the pupil may be experiencing that have not been covered eg depression, anxiety, trauma, substance misuse.(Required)

Please detail the pupil’s strengths and achievements.(Required)

Neurodevelopmental assessment questions

Neurodevelopmental assessment questions for school