Stars Rehabilitation for People of Determination
+971 2 443 0553
Date:
passport-sized photo of child (jpg/png)
Emirates ID of the child (jpg/png)
People of Determination ID Card (jpg/png)
Type:
AutismLearning Disability
Support Equipment:
NoneWheelchair
Others:
Child's name:
Birth date:
Age
Gender:
MaleFemale
Nationality
First Language:
Second Language:
Grade:
School/Nursery:
Mother’s Name:
Age:
Occupation:
Mobile Number:
Email:
Fathers’s Name:
Home number:
Best time to call:
Home Address:
Form completed by:
Relationship to child:
Referred by:
Reason for referral:
Basic living skills:
Self-managementBasic communicationDressingtoiletingGroomingBathing
Education:
writingreadingmathsmemorylearningschool
General Development:
emotionalattentionsocial interactionplayingbehaviourfeedingmemory
Community participation skills:
Basic mobilityShoppingMoney managementSocial awareness
Does your child have a diagnosis?
NoYes
If yes, please specify: e.g. Autism, Attention deficit etc.
Does your child take any medication?
If yes, please give names and dosages:
Previous Surgery/Surgeries?
If yes, please specify:
Speech & Language Therapy (SLT):
Psychology (PSY):
Occupational Therapy (OT)
Psychomotor Therapy (PMT)
Physio-therapy
ABA
Special Education (SE)
Early Intervention (EI)
Nursery
Mainstream Education
Rehabilitation Center
We are aware that we are asking for a lot of information, which is why we are giving it to you to take home so that you have a bit of time to think it through. Please don’t worry if you cannot remember exact ages or details; what we are most interested in is whether or not you had concerns or comments about any of the items below, e.g. was your child late or early with anything. This information is important for us to fully understand your child’s profile.
Birth History
Were there any complications during pregnancy?:
If yes please state:
Birth:
VaginalScheduled C-SectionEmergency C-SectionForcepsVentouses
Length of pregnancy:
Birth weight:
Were there any complications at or after your child’s birth?
Motor (Age)
Rolled over:
Sat alone:
Crawled:
Stood:
Walked:
Grasped Object:
Ran:
Gave object:
Stairs up:
Stairs down:
Self Help Skills (Age):
Fed self with fingers:
Fed self: Spoon
Drank: sippy cup:
Drank: cup:
Drank: straw:
Dressed: help:
Dressed: alone:
Tied Shoes:
Gross Motor (Age):
Jumped:
Rode a bike:
Kick a ball
Throw a ball:
Catch a ball:
Fine Motor (Age):
Palmer (fist) grasp:
Tripod grasp:
Used scissors
Colored in lines:
Printed name:
Writing (reversals)
Headedness:
Right/leftInconsistentNot determined
Toileting:
Toilet with help: (Day)
Toilet with help: (Night)
Toilet independent: (Day)
Toilet independent: (Night)
Hearing /Vision:
Any concerns about his/her hearing?
Recent hearing test?
Grommets?
Have a history of ear infections?
Wear/need glasses?
Visual difficulties?
if yes please describe
Communication
Age at which your child:
Cooed:
Babbled
First words
Put 2/3 words together:
Used sentences:
Put sentences together:
Engaged in conversation:
Understood directions:
Pointed:
Does your child interact with others?
Sample of your child’s first words:
Other observations/concerns:
Please describe if child needs moving and handling needs. Require special equipment or adaptations?
Please describe the concerns you have regarding your child. Is there anything else you think it is important for us know?
Dear Parent/Carer,
Thank you for completing this form. Please submit this form to Stars for Rehabilitation Center for People of Determination who will then contact you for an appointment at the earliest available opportunity.
The information contained in this form is confidential and will not be distributed without your consent. Please be sure to provide any relevant reports and information prior to your appointment.
We look forward to working with you and your child.
Thank you.
I confirm that I have received Stars for Rehabilitation Center for People of Determination policy and agree will the terms and conditions therein.
Name:
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