Hummingbird Learning Centre Assessment Form

Assessment Form

The first step to making progress with any learning or behaviour challenge is to understand the communication and learning style of the individual. For me to understand your or your child’s Learning Style Profile (LSP), please complete the attached form as accurately as possible. While some choices may not apply exactly, please be as descriptive as you can and tick the answers that best fit.

Personal Details

Your or your child`s Name*:

Parent / Guardian Name:
(If under 18)


Date of Birth*

Email*


(Parents) Mobile No*

Home Phone No*

Address*:

Please provide a brief description of the current struggle (s) that you or your child is experiencing, please select all that apply:
Difficulty with ReadingDifficulty with MathsSlow ReaderHas trouble self-starting / daydreamsDislikes ReadingDifficulty completing homeworkPoor Reading ComprehensionFails to hand in assignmentsPoor SpellingDifficulty finishing projectsPoor HandwritingTest anxiety or nervousnessDifficulty with writing/compositionDislikes schoolDifficulty memorizing vocabularySuspect / Confirmed DyslexiaDifficulty memorizing multiplication tableSuspect / Confirmed ADD or ADHD

Please select all that apply:
Excellent Reader (above class level)Enjoys sport or similar activitiesExcellent at Maths (above class level)Enjoys video or computer gamesEnjoys ReadingGood at remembering where things areEnjoys MathsGood at puzzlesEnjoys ScienceAbove average intelligenceEnjoys History or Social StudiesEnjoys learningEnjoys physical activityVery socialEnjoys ArtGood at multi-taskingEnjoys musicOther – See below

Please describe any other talents or abilities demonstrated by you or your child:

Please describe any other interests, activities or areas of study that you or your child enjoys:

Please select (check) all that apply to you or the child's current struggles:
Delayed speech or language skillsFear of school or workAvoids eye contactFear of social situations or groupsDifficulty following instructionsFear of heights or bridgesGenerally or often inattentiveFear of the DarkSensitive to clothing or touchOther Fears or PhobiasOver reacts to changes in routine or scheduleFrequent bedwettingSensitive to criticismFrequent nightmares or night terrorsDifficulty sleepingAllergiesPoor Diet, over or under weightFrequent headaches or migrainesLow self-esteemObsessive or Compulsive behaviours

Please describe any behaviour or emotional issues that you feel might be relevant:

In your own words, please describe any significant emotional events during the most recent 3 years:

Is your child currently under the care of a physician, psychotherapist or other licensed medical practitioner?
YesNo

If yes, please explain the condition(s) for which you / your child is being treated and the nature of the treatment(s), including any medications:

Please include any additional information which you believe may be relevant to the current struggle(s):

Please describe as clearly as possible the results that you would like to achieve:

How did you hear about Hummingbird Learning Centre?

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