Child behaviour questionnaire

Child Behaviour Questionnaire

Please ensure you have a letter from your child’s school, SENCO and anyone else involved in the care of your child. You can attach this to your form by using the file upload feature at the end of the form.

We cannot proceed with any referrals until we have this completed form, as well as a copy of school correspondence and any other assessments by health care professionals.

Please confirm you have read the information above.

Parent/Guardian/Carer Details

This section is to be completed by the parent, guardian, or carer who has responsibility for the child.

Full name: *

Date of birth: *

Telephone number:

Email address: *

Child Details

Please provide the child’s personal details.

Child’s full name: *

What school do they attend? *

Please describe the behavioural problems you are concerned about. Please be as descriptive as possible and give examples:

Are there particular situations which trigger your child’s behaviour?

How long has it been going on for?

Does this happen at home and/or school/nursery?

What is your child’s eating/sleeping pattern like?

Which school do they attend?

What is their behaviour like at school?

Have their teachers expressed concerns?

Is your child disruptive in class?

Are there any concerns that they are behind academically?

Are they having any extra support from school?

Are they on a myPlan/myPlan plus?

Are any other professionals involved with your child or have they been previously? If so please list their name, title and description of how below:

Was there anything remarkable about their pregnancy/birth/early development. Did they walk and talk on time?

Who lives in the household? Please provide names and ages:

What is your child’s relationship like with other household members?

Have there been any significant events in your child’s life e.g. bereavements/divorce/domestic violence/bullying?

How have the behavioural problems impacted your family?

What are your concerns? Are you concerned about a specific diagnosis? Is there anything you think may help?

Please upload any relevant information in relation to this Child Behaviour Questionnaire.

Maximum file size: 67.11MB

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Parent/Guardian/Carer Details

Child Details