Research Form

To help our research, please fill out this form and then press the submit button. To preserve your privacy simply use initials, or nicknames, or just 'father', 'daughter #3', etc to describe the people.(But please try to make sure there is no confusion, by, for example, using the same initials, e.g. 'F.G.', for both a sibling, and a teacher!)

The Child
Name of Child:
Sex of Child:
  BOY   GIRL
Child's Date of Birth
Date Form Completed
Child's Age Then Years Months

The Child's Ability
average
below average
well below average
What is the child's mental age?
i.e. what age of normal child does the child act like?
Years Months
Describe the child's ability in more detail

How does the child communicate to others?

 How does he/she show what he/she wants?

just cries to show she wants something, but can't show what just tries to get the thing herself
takes people to places and objects,
e.g. pulls mother to kitchen to show she is hungry 		gives people objects she wants something done with, e.g. gives mother her drinking glass she wants juice put in
points to what she wants uses sign
uses photos uses speech
uses symbols
Describe the child's communication in more detail

How does the child understand others?
from the situation, (n.r.a.,t.r.a.) from others' gestures
from photographs from symbols
from signs from speech
Describe how the child understands others in more detail

The Child's Personality
timid,shy,nervous tough
aggressive to others hyperactive
underactive likes to be with people
likes to be by himself/herself aggressive to self
Describe the child's personality in more detail

The Child's Interests
Does the child like dolls, teddy bears etc?
Yes No
If yes, what does she do with them?
Describe the child's interests in more detail

The Child's Behaviour
looks at hand(s) bites hand(s)
slaps hand(s) sucks thumb
kisses hand(s) hits chin with hand(or presses hand against chin)
hits head with hand(s) chews clothes, e.g. front of T-shirt
pulls his/her hair picks nose
sucks clothes, (including 'comfort cloth')
Describe the behaviour in more detail. For example is only one hand
involved or both? If one hand, is it always or usually the same hand?
If yes, which hand, left or right? If the child brings one hand (which
one?) to his chin, does he use his other hand to help to bring it there?

The Behaviour History
How old was the child when the behaviour started?
Years Months
What important things happened around that time?
Does the child still show the behaviour?
Yes No
If not, when did it stop? Why do you think it stopped?
Describe the history of the behaviour in more detail

The Causes, what Triggers the behaviour?
What happens just before the child shows the behaviour?
nothing you can see
adult interacts positively with child, e.g. gives him a hug
adult interacts negatively with child, e.g. tells child off
What do you think causes the behaviour? Describe in detail.
If the child shows more than one type of behaviour, e.g.
hand biting and hand kissing, please say what usually comes
just before each different type.

How do others react to the behaviour?
do nothing, ignore
look at child
tell the child off
frown at child
do something nice with child, 'divert' him,
(but actually reward him for the behaviour!)
How do others react to the behaviour? Describe in detail.
Different people may react in different ways. For example
dad might ignore the behaviour, and mum might tell the
child off for it. So say who does what.

The Family
Who does the child usually live with?
mother and father just mother
grandparents just grandmother
aunt other
If with 'other' person or persons, who with?

The School
Does the child go to school?
Yes No
If no, why not?
If yes, what kind of a school is it?
day school boarding school
ordinary school special school
Use this space for any final comments or questions.
When you press the 'Submit Form' button you will receive a privacy warning. Please do not be scared off by this, as you will hopefully not have used the real full names of the people mentioned in the form. All who return properly completed forms will be rewarded with a small fee or by being offered free professional advice on their child's problems. If you wish to avail yourself of this service describe the problem in the last box of the form. Replies will be to your own e-mail address.
Bogus completions of the form are easily detected and will be dealt with appropriately
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