Case history

Child's name*

First Last

Date of birth*

Today's date*

Age in years*

Current School*

Grade/class*

Home Language(s)*

From whom / where did you hear about us?*

Reason for application*

PREGNANCY

Was this a planned baby?*

Yes

What was the mother’s age when pregnant?*

in years

What was the duration of the pregnancy?*

in weeks

Were there any complications during pregnancy?

(e.g. German Measles, Hepatitis, Toxaemia, Threatened Miscarriage, Persistent Vomiting, Medications, Emotional Problems)

What was the duration of the labour?*

in hours

Were there any complications during delivery?*

Yes

Please give details of the delivery complications

Was the first cry immediate or delayed?*

Immediate

Delayed

Please give any other relevant birth history

POSTNATAL / INFANCY

Were there any complications immediately following the birth?

Describe any feeding problems in the first year.

Were there any adverse reactions to inoculations?*

Yes

Were there any other problems during infancy?*

Yes

(e.g. restlessness, lethargic baby, severe colic, constant screaming, sleep disorders, etc.)

Please give details of the other problems*

Were there any changes or a constant figure?

EARLY CHILDHOOD

Please give details of any childhood illnesses

Please give details of any high fevers, seizures or convulsions your child may have had

TEST RESULTS AND CURRENT MEDICAL HISTORY

EEG place

EEG date

Month

Day

Year

EEG results

Is your child on any medication with regard to this?*

Yes

Eye tester

Eye test date

Month

Day

Year

Eye test results

Hearing tester

Hearing test date

Month

Day

Year

Hearing test results

Has your child ever been hospitalized (details, length of stay?)

Has your child undergone any surgical procedures (details, dates)?

ALLERGIES

Please list any allergies your child may have

Is your child on any medication at present? Please give details

FAMILY MEDICAL HISTORY

Please describe any medical, emotional or scholastic problems either in the immediate or extended family (grandparents, aunts, uncles, cousins, etc.), which may be relevant (e.g., cognitive challenges, dyslexia, autism, learning barriers, hyperactivity, speech or hearing problems, different ability, epilepsy, substance abuse, etc.).

DEVELOPMENT MILESTONES

Motor Skills - approximate age at which your child mastered these skill

Sit momentarily alone*

Crawl alone*

Walk alone*

Button own clothes*

Lace own shoes*

Speech and Language Skills – approximate age at which your child mastered these skills

Babbled*

Said first word*

Combined two or more words*

Toilet trained*

PRE-SCHOOL BEHAVIOURS

During early childhood (2 to 5 years) which of the following were true of your child?

“In another world”

Afraid of heights

Avoided contact with textures

Bedwetting

Changeable moods

Didn’t respond when called

Excessively fearful

Followed instructions correctly

Frequent nightmares

Listened attentively to stories

Mixed handedness

Much whining / crying

Severe temper tantrums

Slow in feeding / dressing

Soiling

Sucked thumb / fingers

Unintelligible speech

Unusually active

Unusually angry

Unusually clumsy

Unusually frustrated

Did / does your child struggle with sensory sensitivity?

Were there any other pre-school behaviours you consider relevant? Are any of these still present today? Please list them and explain.

PRESENT BEHAVIOUR AND ACTIVITIES

Rate your child on the following

Athletic ability*

Clumsy

Average mobility

Athletic

Fine motor ability*

Difficulty with pencil tasks

Average mobility

Usually adept with pencil

Communication ability*

Difficulty expressing self verbally

Average expressive language

Unusually expressive

Social ability*

Withdrawn / Prefers to be alone

Friendly

Very social

Focus ability*

Inattentive, inability to focus

Average ability to focus

Concentrates exceptionally well

State ability*

Impulsive, explosive

Average temperament

Calm, even tempered

Independence ability*

Excessively dependent

Average

Overly independent

Fear level*

Excessively fearful

Has normal fears

Fearless

Emotional*

Depressed

Regulated Emotion

Extremely cheerful

Discipline*

Responds well to discipline

Some discipline problem

Major discipline problem

Are there any other behaviours or traits that are relevant?

Describe your child’s sleep patterns

How do you think your child feels about himself/herself in comparison to other children?

What are your child’s interests and hobbies?

SCHOOL HISTORY

School history*

Starting from nursery school and going up to the current grade.

Grade/class

Year

Age

Name of school

Comments

Please include any problems noted and comments on relationships with peers and with teachers.

Indicate the medium of instruction (language) for these years and note any changes made (e.g. from first to second language).

List all languages spoken in the home and estimate as a percentage the time spent speaking these at home.

Language

Time spent speaking it as a %

Have any of the following comments been made by professionals about your child?

Finishes work on time

Behaviour problem at school

Participates in class discussions

Last to complete work

Completes homework independently

What are your child’s favourite subjects?

What are your child’s extramural activities?

PREVIOUS THERAPY / ASSESSMENTS

Please give details of previous therapy/assessments

Assessment type

Date

Name of Professional

Results/recommendations

FAMILY RELATIONSHIPS

Describe child’s relationships with family members where relevant, note details if there has been a divorce, death, etc., including dates and indicate if the relationship with each is good, fair or poor

Relative

Name

Relevant details

Good/fair/poor

Are there any other important relationships (stepsiblings, grandparents, etc.,)? Please describe

Who is responsible for discipline in the home and how is it done?

Are there any relevant social or emotional problems within the family unit?

Describe marital relationships in general.

Who supervises your child after school?

Were there any pregnancy / birth / subsequent difficulties with other children?

FUTURE PROSPECTS

Briefly describe your goals for and expectations of your child in the future.

What do you consider your child’s areas of greatest need? What are your expectations of us in assisting him/her to attain these goals?

Please use this space to add any personal comments you would like to make about your family or your child, comments professionals have made, concerns not yet addressed, trauma, brushes with educational or legal authorities, or any other relevant factors which would be helpful in understanding your child.

Describe the way in which YOU see your child, in respect of personality traits, strengths and weaknesses.

Describe what vocation / occupation YOU see your child involved in.

Describe what vocation / occupation YOUR CHILD would like to be involved in.

Any assessments and reports you think we should have?

Drop files here or

Max. file size: 64 MB.

Tell us about the assessments and reports you uploaded above?

Completed and signed by

First Last

Disclaimer

I agree to the disclaimer.

In line with The Protection of Personal Information Act (POPIA), Glenoaks will attempt to ensure the confidentiality of personal learner and parent/guardian information. All reasonable measures will be in place to protect personal information. Please note that personal information collected from this application and placement process will be stored electronically (password protected) on email by the principal, head of marketing, bursar, and head of administration. Printed documents will be stored in a secure record storeroom for a period of 2 years, should the child not be enrolled at Glenoaks. The credit check information will be used to perform a TPN credit reference check, run by our bursar, and stored by our bursar electronically and in a securely stored file for a period of 2 years, should the child not be enrolled at Glenoaks. The reason for storage is so that a re-application in this time period will be easier.
In order for the trial period to be undertaken, the documentation (excluding the credit check information) is read by the teacher/s, therapists and HOD’s who are observing the child. The next of kin information is required in the event that they need to be contacted during a trial period. Once enrolled, the information is kept as per our POPIA policy for enrolled learners (including parents/guardians). By submitting your application, you recognise and accept this disclaimer.

Current date*

Signature

COMPLETE YOUR DETAILS BELOW

PREGNANCY

POSTNATAL / INFANCY

EARLY CHILDHOOD

TEST RESULTS AND CURRENT MEDICAL HISTORY

ALLERGIES

FAMILY MEDICAL HISTORY

DEVELOPMENT MILESTONES

Motor Skills - approximate age at which your child mastered these skill

Speech and Language Skills – approximate age at which your child mastered these skills

PRE-SCHOOL BEHAVIOURS

PRESENT BEHAVIOUR AND ACTIVITIES

Rate your child on the following

SCHOOL HISTORY

PREVIOUS THERAPY / ASSESSMENTS

FAMILY RELATIONSHIPS

FUTURE PROSPECTS