Child Development & Skills Assessment Tool

Child's Details

Full Name

Date of Birth

Age

Gender

Class / Grade

School / Centre

Date of Assessment

Assessed By (Evaluator)

Diagnosis (if any, optional)

Name to use in report text (optional)

Parent / Guardian Name

Relationship to Child

Phone Number

Email

Address

Family's main goal (optional) — completes “The family's main goal is for the child to …”

Concerns raised (one per line)

Areas of Concern (select all that apply)

Any specific behaviour worth noting

Type of Family

Economic Stability

Changes in Family Relationships (if any)

Parent's Behaviour (select all that apply)