Extra Lesson Program

Complete the QUESTIONNAIRE below

Fill out and submit the Child Development Questionnaire below.
(This questionnaire helps us understand your child’s developmental history and any challenges they may be experiencing.)

Download the Supply List for Extra Lesson Classes

Child’s Developmental History & Background Questionnaire Introduction: This form is designed to help understand your child’s developmental history and any challenges they may be experiencing. This information will help me plan an appropriate screening. Please answer the questions as thoroughly as possible. Remember, this screening is not intended to diagnose but to identify potential areas of support.

Note: This screening aims to gain insight into your child’s development and help identify areas where additional support may be beneficial. I am not a medical professional, and it is not my role to diagnose medical or psychological conditions. If significant concerns arise during the screening, I may recommend consulting with a qualified professional for further evaluation.

Child's Full Name

First Name

Last Name

Child's Date of Birth

Parent/Guardian's Full Name

First Name

Last Name

Contact Email

Contact Phone Number

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Developmental & Medical History:

Was your child born full-term? (If not, please specify the number of weeks/months early or late.)

Were there any complications during pregnancy, birth, or shortly after birth?

Did your child reach significant developmental milestones (such as crawling, walking, talking) within the expected timeframes? (If not, please explain.)

Has your child experienced any significant illnesses, accidents, or surgeries?

Does your child have any known medical conditions or diagnoses? (If yes, please list and provide relevant details.)

Has your child experienced any noticeable vision, hearing, or speech issues?

Is your child taking any medication currently?

Behavioural & Social Information:

How does your child respond to social situations or new environments? (e.g., outgoing, shy, anxious, etc.)

Does your child have any sensory sensitivities? (e.g., sensitivity to loud noises, certain textures, strong smells, etc.)

How does your child handle transitions or changes in routine?

Does your child display any repetitive movements or behaviors? (e.g., hand- flapping, rocking, etc.)

What activities does your child particularly enjoy or excel at?

Does your child avoid certain activities or tasks? If so, please describe.

Physical & Motor Skills:

How would you describe your child’s balance and coordination?

Have you noticed any challenges with your child’s fine motor skills? (e.g., holding a pencil, using scissors, buttoning clothes, etc.)

Have you observed your child struggling with gross motor tasks? (e.g., running, climbing, bike riding, skipping, etc.)

Does your child often bump into things or seem uncoordinated?

Does your child appear physically restless or have difficulty sitting still?

Emotional & Cognitive Information:

How would you describe your child’s mood or emotional state most of the time?

Does your child show signs of anxiety, worry, or frequent mood swings?

Does your child exhibit signs of difficulty concentrating or paying attention?

How does your child manage frustration, anger, or sadness?

Have there been any significant changes in your child’s behavior recently?

Learning & School Information:

How does your child feel about school and learning?

Have teachers or caregivers expressed concerns about your child’s development or behavior?

Does your child find it challenging to follow instructions or complete tasks independently?

Is there a particular subject or activity that your child finds incredibly challenging?

Have you or your child’s teacher noticed any academic difficulties, such as trouble reading, writing, or doing math?

Family Information:

Have any significant changes in your child’s life or environment recently (e.g., moving, new sibling, divorce, etc.)?

Does your child have a consistent daily routine?

How would you describe your child’s sleep patterns?

Are there any family medical or developmental histories that you believe are relevant?

Is there anything else you would like to share about your child?