CHILD CONFIDENTIAL QUESTIONNAIRE  

PERSONAL DETAILS  

DEVELOPMENT HISTORY  

Yes
No
Yes
No
Yes
No
Yes
No

SCHOOL HISTORY  

Current National Curriculum Levels (if appropriate) 
What are the particular difficulties exhibited in school?  
Slight
Moderate
Severe
Slight
Moderate
Severe
Slight
Moderate
Severe
Slight
Moderate
Severe
Slight
Moderate
Severe
Yes
No
Yes
No
Unavailable
Yes
No
Yes
No
Yes
No
Yes
No

BACKGROUND INFORMATION  

Yes
No
Yes
No
Yes
No