School Consent Lara Berman Physiotherapy

Parent/Guardian Information for Physiotherapy Assessment

As I am performing an assessment on your child at school, I would appreciate it if you could fill in the following information so that I have a better understanding of your family situation, and your expectations from physiotherapy.

Name of Child *

First

Last

Date of Birth *

School and Class *

Teacher’s name *

Family Doctor *

Mother’s name *

First

Last

Mother's Email *

Father’s name *

First

Last

Father's Email *

Home language *

Reason for referral/ Current concerns *

Other Therapies: (Previous and Current). Please supply the therapist’s name and contact details. *

I consent that Lara Berman may contact the relevant therapists treating my child *

Have there been any significant recent life events that could have affected your child? *

(eg: death of a relative, divorce, moving houses, new sibling etc.)

What are your concerns regarding your child *

What do you consider to be your child’s strengths? *

What do you consider to be your child’s weaknesses? *

How has your child’s academic record been? How is his/her participation in class? *

Any other relevant information: *

Who was the questionnaire completed by *

Date: *

Thank you for taking the time to complete this additional information!