Head2Toe Parental/Guardian Questionnaire

To get an idea if a child is suitable for the Head2Toe programme, this questionnaire is to be completed by the childs parent/guardian before a screening session can be arranged.

Questionnaire Form

Please Complete All Fields

Childs name

Date of Birth

School

Class

Teacher

Therapist (OT/PT)

Therapist Practice

ICE Phone

Parent/Guardian Name

My child enjoys physical activity

Please select

My child plays sports after school

Please select

My child likes to try new things

Please select

My child has good focus and concentration

Please select

My child plays well with others

Please select

My child is energetic

Please select

My child is described as clumsy by others

Please select

My child has a high self-eﬃcacy

Please select

My child feels good about himself/herself

Please select

My child tries hard

Please select

My child wants to be good at sports

Please select

My child has challenges with motor skills

Please select

My child is very interested in:

Please complete the sentence

My child’s favourite thing to do afterschool is:

Please complete the sentence

My child is happiest when:

Please complete the sentence

My child is least happy when:

Please complete the sentence

My biggest concern for my child is:

Please complete the sentence

The teacher’s biggest concern for my child is:

Please complete the sentence

My child was diagnosed with Developmental Coordination Disorder (Dyspraxia) by:

Please complete the sentence

My child has received help for motor skill challenges from:

Please complete the sentence

During the sessions, my child and the therapist work on improving:

Please complete the sentence

My child's motor skill challenges consist of:

Please complete the sentence

These motor skill challenges impact my child’s life by:

Please complete the sentence

Other medical concerns which could explain my child’s motor skill challenges have been identiﬁed as:

Please complete the sentence

Through Head2Toe, I hope my child will learn how to:

Please complete the sentence

Through Head2Toe, my child hopes to improve at:

Please complete the sentence

Head2Toe Parental/Guardian Questionnaire

Questionnaire Form

info@head2toeireland.com

087 6199621