Prospective Student Questionnaire

Please note that this questionnaire is not designed to provide us with all information, but merely to give us a better understanding of your young adult. Please provide all information that you feel may be relevant to our assessment of your young adult’s suitability and needs. Please also note that although every effort will be made during the assessment process to obtain relevant information, the obligation to disclose such information remains with yourself. Failure to disclose relevant information may result in it being determined that the services offered are not suitable to meet the needs of your young adult. In such an event, and given that you have signed a contract, you will be responsible to meet the obligations of that contract.

Please answer as truthfully and as comprehensively as possible. Every effort will be taken to treat the information provided as strictly confidential.

Please complete the form below to the best of your knowledge – thank-you!

Prospective Student Name(*):  Age(*) :   Date of Birth(*) :

Parents / Caregivers Names :(*) :

Telephone (Home) :   Telephone (Work) :   Cell Number (*) :

Email Address (*) :

1. CHILDHOOD DEVELOPMENT

1.1. Complications during pregnancy or at birth? (e.g. premature)

1.2. Generally, was he/she a healthy baby and child? YesNo

If No - please provide details below.

1.3. Were developmental milestones normal? YesNo

1.4. At what age did he/she start walking?

1.5. At what age did he/she start talking?

1.6. Schools attended (Please list)

1.7. Academic performance (please provide brief details of your young adult’s participation and advancement in schooling)

1.8. Highest grade passed (special or mainstream school):

2. CURRENT FUNCTIONAL ABILITIES

(Please provide the answer that best describes your young adult’s current level of functioning.)

2.1. Clarity of Speech: Severely Impaired / Slightly Impaired / Normal

2.2. Conversational Ability (ability to talk to others): Severely Impaired / Slightly Impaired / Normal

2.3. English Language Comprehension: Poor / Basic / Average / Advanced

2.4. Literacy (reading and writing): Poor / Basic / Average / Advanced

2.5. Money Management (handling / managing money): Unable / Needs some assistance / Independent

2.6. Cooking & Cleaning: Unable / Needs some assistance / Independent

2.7. Traveling / Use of Transport: Dependent (can’t travel alone) / Needs some assistance / Independent

2.8. Forming and maintaining relationships within home environment (e.g. with siblings, parents, primary caregiver). Please comment.

2.9. Forming and maintaining relationships outside the immediate home environment (e.g. with peers, work colleagues). Please comment.

3. PSYCHO-SOCIAL FUNCTIONING

Please indicate how often your young adult displays the following:

3.1. Anxiety: Never / Rarely / Occasionally / Frequently

3.2. Depression / Low Mood: Never / Rarely / Occasionally / Frequently

3.3. Tearfulness / Crying: Never / Rarely / Occasionally / Frequently

3.4. Verbal Aggression (e.g. swearing or shouting): Never / Rarely / Occasionally / Frequently

3.5. Physical Aggression (in any form): Never / Rarely / Occasionally / Frequently

3.6. If there has been any form of physical aggression, how is this displayed? (e.g. kicking, lashing out at others/objects, fighting with others)

4. MEDICAL HISTORY

4.1. Has your young adult been assessed, diagnosed or treated by a health care professional in the last 2 years (e.g. a neurologist, psychiatrist, psychologist or occupational therapist)? YesNo

If yes, please provide a brief description of the outcome of the assessment / diagnosis/ treatment.

Please bring any results / reports to the screening appointment

4.2.Has your young adult formally been diagnosed with an intellectual disability? YesNo

If yes, please provide details below (diagnosing specialist, date of diagnosis)

4.3. Has your young adult been diagnosed with a mental illness / mental disorder? YesNo

If yes, specify the outcome of the diagnosis and any treatment received.

4.4. Has your young adult ever sustained a head injury / significant trauma to the head? YesNo

If yes, please provide details below.

4.5. Has your young adult ever been involved in any serious accident? YesNo

If yes, please provide details below.

4.6. Does your young adult have epilepsy, panic attacks or pseudo-seizures? YesNo

If yes, please provide details below.
Frequency and duration of attack / seizure:

General time of day of attack/ seizures: Anytime / Mornings / Afternoons / Evenings

Triggers for an attack/seizure (for e.g. heat, exhaustion, stress):

Effect of seizure: (e.g. drowsiness, loss of co-ordination, aggression)

4.7. Does your young adult have any physical disability? YesNo

If yes, please provide details below.

4.8. Please list all current medication and what it is prescribed for.

4.9. Please list relevant past medication.

4.10. Do you believe that your young adult has an intellectual disability or learning challenges?

5. CRIMINAL RECORD

The following information will be treated as confidential but is vital for us to know beforehand.

5.1. Has your young adult ever been convicted of a criminal offence (i.e. found guilty of a crime in a court of law)? YesNoNot Sure

5.2 Does your young adult have a criminal record? YesNoNot Sure

5.3 If yes, please provide details regarding the date and nature of the conviction / criminal record (i.e. what was the conviction for)?

6. GENERAL

Where did you hear about The Living Link?

Any other Comments

By submitting this form, I hereby declare that the information completed above is true and correct.

We want to make sure that you are a human being so please enter the code below – thanks!

captcha