Consultation with parents

Children from 1 to 6 years

Fiskervaenget 19

DK-4390 Vipperod

Phone: +45 7020 1509

Mail:

Data:

Child’s name:Date of birth:

Mother’s name:Date of birth:

Father’s name:Date of birth:

Brother’s/sister’s name:Date of birth:

Brother’s/sister’s name:Date of birth:

Address:Zip code/town:

Community:Mobile phone 1:

Mail: Mobile phone 2:

Date for consultation:Consultant:

(Consultantis to be filled out bythe Rafael Centre)

Gestational week:Birth weight:

Reason for approach to the Rafael Centeret(max 5 lines):

During the consultation we will give you:

  • Explanations for the child’s reactions and special needs
  • Immediate options for care and handlingin daily life
  • Proposals for a concrete action plan

Please fill out the form below in Word and in short terms and email

I/we give the Rafael Centre the permission to register any information here given and other oral or written information given by me/us during my/our cooperation with the Rafael Centre.

The information is confidential and will exclusively be available for consultants and therapists connected to the Rafael Centre. It will not be handed over to third-party.

(mark with an ’x’)

Yes please, I/we would like to sign up for the Rafael Centre’s news mail

(mark with an ’x’)

The child’s history as to life in the uterus/womb, the birth and the course after the birth
Pregnancy:
Birth:
Course after the birth:
Access to the child/separation:
Breast feeding:
Experiences or situations of greater significance from infancy until today?
(e.g. betrayal, shock, trauma)
What are your biggest concerns for your child?
How and when is it being expressed? (is the child restless, too passive etc.)
Ability of integrating sense impressions/development in motor functions/personal skills
The physical foundation
Sense of muscles (proprioceptive sense), coarse motor control:
e.g.clumsy, stumbles, holds things too lose/tight, difficulties in catching balls, tight or soft muscles
Detailed motor control:
e.g. difficulties in holding a spoon/fork/pencil, playing with blocks/pearls, button/unbutton
Sense of balance:
e.g. spins/whirls unfettered, is easily dizzy, falls, is passive or hyper active, has a need for contact with the ground/floor, becomes car-, air or seasick
Sense of touch (tactile sense):
e.g. negative reaction at physical contact/light touch, unpleasant feeling by touching greasy stuff
Sensitive to sounds, light, smells:
Activity level:
The cognitive foundation
Language:
Visual memory:
Verbal memory:
Attention/concentration:
Learning ability:
Influence on the forming of personality
Stress limit/stress handling/feeling safe:
Connection to others/bonding:
Self-esteem, self-understanding, self-confidence:
Social skills/behaviour:
Related to age, but e.g.: shows initiative and intentions, can use the language for conflict solutions, can put down limits for him-/herself, can wait for own turn, shows empathy
Circumstances of childcare (comprising wellbeing and pedagogical settings)
Eating pattern, nutrition, food supplements
Toilet habits and functioning of digestion
Sleep
Night and day and rhythm (stable or variant?)
Infections, health
Possible diagnoses
Training/treatment/therapy till now
Personality, potentials, interests
Family relations
How are the parents – is it and/or has it been tough? Do you receive professional support?
Do you receive support and understanding from friends and family?