1. Personal Information

Child's Name:

Age: 

Gender: 

Parent/Guardian's Name: 

Contact Information:

 2. General Health 

a) Has the child been diagnosed with any medical conditions or chronic illnesses? If yes, please specify. 

b) Are there any current or past medications the child is taking? If yes, please provide details.

3. Emotional Well-being 

a)Does the child display signs of anxiety, such as excessive worry or fear? 

b) Has the child been experiencing frequent mood swings or sudden changes in behaviour? 

c) Does the child often seem sad or withdrawn? 

d) Has the child expressed feelings of hopelessness or worthlessness? 

e) Does the child have difficulties managing stress or coping with challenging situations?

4. Behavioural Patterns:

a) Does the child display disruptive behaviours at home, school, or other social settings?

b) Does the child have difficulties following instructions or rules?

c) Has the child exhibited any aggressive or violent behaviors towards others or themselves?

d) Does the child engage in repetitive behaviors or rituals?

e) Does the child struggle with attention and focus?

5. Social Interaction:

a) Does the child have difficulties making or maintaining friendships?

b) Does the child exhibit social withdrawal or isolation?

c) Does the child struggle with communication skills, such as difficulties expressing themselves or understanding others? 

d) Has the child experienced bullying or teasing? 

6. School Performance 

a) How is the child's academic performance? Are there any specific subjects or areas of difficulty? 

b) Does the child have any learning difficulties or challenges? 

7. Family and Environmental Factors 

a) Are there any significant changes or stressors in the child's family or home environment? 

b) Has the child experienced any traumatic events or significant life changes? 

c) Are there any family history or genetic factors related to mental health concerns? 

8. Additional Information

1. • Is there any other information or concerns you would like to share about the child's mental health?

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