Create-abilities Schools Questionnaire

PRIMARY SCHOOL QUESTIONNAIRE

Create-abilities
Your student has an Occupational Therapy Assessment with Nadia Brown at Create-abilities. Your knowledge and opinions of this child is important and valued. Your assistance is greatly appreciated in the completion of this questionnaire prior to the assessment. This will enable an overall insight into this child's abilities and enable the assessment to focus specifically on problem areas highlighted.
Please fill in the form below or if you prefer to print a questionnaire and post it to Create-abilities, CLICK HERE

Student name year age male female

School Principal Phone

has he/she been assessed by a school counsellor? yes no
comment

does he/she receive aide assistance/learning support? yes no
general comments on school strategies currently in place to support this student

what do you perceive this student's strengths to be?

what are your primary concerns in regard to difficulties affecting this child's performance at school?

ACADEMIC ABILITIES
handwriting reading spelling

creative writing math

ATTENTION & PARTICIPATION
attention & concentration, instruction following, task completion, organisation skills, behaviour, peer relations,
group participation, level of adult supervision required
comments

HANDWRITING
pencil grip, letter formation, reversals, letter sizing, spacing, speed, fluency, cursive
comments

FINE MOTOR SKILLS
scissor skills, ruling lines, art and craft, manipulation of small objects, construction skills
comments

GROSS MOTOR SKILLS
confidence, coordination, balance, strength, endurance, playground skills and participation
comments

SENSORY PROCESSING impulsive & always on the go, touches all objects and people more than others, sensitive to certain types of touch & doesn't like to be bumped, stands on outskirts or at end of lines, poor tolerance for change of routine, sensitive to loud noises, always notices movements/noises around the room
comments

name of person completing questionnaire
position date

please contact Nadia at Create-abilities if you wish to further discuss this student's needs on
0420 942 129 nadia@create-abilities.com.au
Nadia Brown, Paediatric Occupational Therapist, B.App.Sc.(OT), MHS(OT), AccOT.