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Registering or Enquiring about Psychoeducational Assessments (6 to 21 yrs old) / Literacy and Language Interventions (7-12 yrs old)

Please complete all required fields and sections.

Select for which purpose you want to enquire:

Contact Information Further Contact Information Medical / Developmental / Educational Information Consent

Contact Information

If you are a referring agent/parent making an enquiry or referral, please fill in the following:

Name of Person Enquiring/Referring

Relationship To Child/Youth

Referring Party

Contact Number of Enquirer or Referrer

Email Address

Child's Name as per NRIC

Child's Preferred Name

Child's last 4 Characters of the NRIC

Child's Biological Sex

Child's Date of birth

The service I am enquiring about or registering for

If you are enquiring/registering for Literacy and Language Interventions, please indicate your preferred SHINE site. (All intervention referrals are required to undergo a screening to determine suitability.)

What is your Enquiry?

Further Contact Information

Please continue to fill the following as best as able.

Child's Citizenship

Child's Race

Please fill in the Child's Address:

Block / Unit Number

Street

Building Name

Postal Code

Country

Child's School

Child's School (Others)

Child's School Level

Child's School Level (Others)

Child's Religion

Child's Preferred Language

Child's Drug/Food Allergies

Parent/Guardian's Name

Parent/Guardian's Contact Number

Parent/Guardian's Preferred Language

Parent/Guardian's Email

Parent's Marital Status

Second Parent/Guardian's Name

Second Parent/Guardian's Contact Number

Second Parent/Guardian's Preferred Language

Second Parent/Guardian's Email

Family Type

Family Combined Gross Income (please estimate if you are unsure)

Number of Household Members

CHAS Card

Housing Ownership

Housing Type (Living Room + Number of Bedrooms)

Housing Type (Others)

Family members (multiple family members):

Name	Age	Relationship to Child	Occupation	Income	Education	Emergency Contact

Medical / Developmental / Educational Information

Please continue to fill the following as best as able.

Medical History/Physical Health (e.g., any major illnesses? any hearing or vision difficulties?)

Developmental History (e.g., birth information, developmental milestone issues)

Temperament, Activity Level, Mood, Concentration Span, Self-esteem, Social Skills

Educational Concerns (e.g., comments from teachers or parents on academic work)

Any Previous Formal Diagnosis?

What are some learning support or other programmes that the student is attending at school?

What are some learning support, other programmes, services or, therapy the student is receiving outside of school?

Any Other Comments/Information

Consent

Has the person you are referring consented to the referral?

I acknowledge that I have read and understood SHINE’s Data Protection Notice (also available on our website www.shine.org.sg), and consent to the collection, use and disclosure of my personal data by SHINE Children and Youth Services for the purposes set out in the Notice.

I consent to the collection and use of my and/or my family member’s photographs and other audio-visual information.

Registering or Enquiring about Psychoeducational Assessments (6 to 21 yrs old) / Literacy and Language Interventions (7-12 yrs old)

Select for which purpose you want to enquire:

Errors:

Contact Information

Further Contact Information

Family Members

Medical / Developmental / Educational Information