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Understanding Your Child
- Looking Beneath Behaviour
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Home
Parent Support
Understanding Your Child
- Looking Beneath Behaviour
How I Work
Resources
About
Contact

Call 0474 095 432

Child Development History

Child Development History

This intake questionnaire will help me get to know your child, and what brings you to therapy.

Please complete and return before your first visit.

Child's Name

Date of Birth

Age

Parent/Carer name

Relationship to this child

Address

Email

Preferred Phone

What are your main concerns about your child?

Siblings / step-siblings and their ages

Current Medications

Current Medical Concerns / any diagnoses?

Is your child currently seeing another counsellor, psychologist or psychotherapist, or have they seen someone in the past?

Maternal stress levels during pregnancy?

Any family stress, shocks or overwhelming experiences during your child's first 7 years?

Milestones in first 12 months - early, late, generally on target (rolling, tummy creeping, crawling, walking)

How would you describe your child - easygoing, stressed, sensitive, restless, happy, gentle, creative, stresses easily, easily overwhelmed?

Age starting childcare

Age starting school?

School Experience

Struggles with reading, hand writing, maths, spelling, listening, written expression Restless and fidgety in class, finds it hard to sit still Enjoys being at school Avoids / hates going to school Clingy, struggles to let go of mum Struggles to wake in the morning Headaches, tummy aches before school Tends to act out in class, often gets into trouble Tends to dissociate in class, gaze out the window, often "off with the fairies"? Makes friends easily

Mood after school

Angry, restless Anxious, shutdown Talkative, happy Exhausted, tired, moody

Favourite games, hobbies, interests, story book characters?

Any favourite sporting (or other) heroes?

Plays alone, socialises easily, makes friends easily, loves company, loves playing outside?

Exposure to television, digital devices, smart phone - hours per day?

Describe your child's behaviour when stressed - tantrums, acts out, withdraws, shuts down?

What are your child's special gifts and talents?

What is it about your child that delights you the most?

Why are you here? What would you like to achieve from these counselling sessions?

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Helpful Links

Home
Parent Support
Understanding Your Child
- Looking Beneath Behaviour
How I Work
Resources
About
Contact

Home
Parent Support
Understanding Your Child
- Looking Beneath Behaviour
How I Work
Resources
About
Contact

Contact Information

0474 095 432
rosalind@rosalindveness.com.au
South Head, Moruya, NSW

©2026 Rosalind Veness. All rights reserved.

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