Pre-Consultation Form (Age 2-11)
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First Name
Last Name
Email
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Phone
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Country
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First and last name of child
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Date of birth
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Age of child
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Age and sex of siblings
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Other people living in the home
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What would you like me to support you with in the consultation? What would you like most from me in our time together?
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Which books by Aletha Solter have you read?
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Describe any major fears your child has had in the past or now?
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TV viewing: How many hours per day/week does your child watch TV? What programs does s/he watch?
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Has your child had temper tantrums? If yes, describe:
How many hours per day (or per week) does your child cry or rage now?:
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Social Development:
Describe any problems your child has had (or has now) relating to siblings or other children?:
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Physical Development:
Describe any physical problems, special needs, or medical problems:
At what age did your child first crawl?
At what age did your child first walk? Etc:
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Cognitive development:
Describe any learning difficulties or special needs: Caretaking arrangements/School:
Describe your child's caretaking arrangement during the first year:
Describe your child's current caretaking arrangements?
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Learning styles/Sensitivities:
Of the seven forms of intelligence that follow, which ones best characterise your child: 1) logical-mathematical, 2) verbal-linguistic, 3) visual-spatial, 4) kinesthetic (good motor skills & coordination), 5)
musical
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Strengths:
What are your child's strengths? What does your child do well?
What do you enjoy the most about your child?
Describe your strengths as a parent. What do you do well?:
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Did your child /you experience any birth trauma?:
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Any other stresses or traumas to date?:
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Miscellaneous:
Give any other pertinent information about your child, yourself, your relationship with your child, your living situation, or your concerns:
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I agree to the terms & conditions. See URL. https://www.flourishingchildhood.com/terms-conditions.
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