Speech Pathology Intake Form

Speech Pathology Intake Form
Name

First NameLast Name
Date Of Birth

MonthDayYear
Date
Gender

MaleFemaleOther
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile
Email
example@example.com
Phone
Do you have a pension card?

YesNo
Do you have private health insurance?

YesNo
If yes, please provide name and card number
Doctor/Referrers name?
Medicare Number and expiry date
Emergency Contact
Emergency Contact Number
Please enter a valid phone number.
Relationship to Client?
What is the reason for presenting to Cross Care today?
Birth History - Were there any problems during pregnancy and/or birth? Yes or No (If yes, briefly describe)
Home Environment - Who lives at home with the child? (Siblings (and ages), mother, father, step-parents, grandparents, etc)
How often is English spoken at home?

AlwaysMost of the timeSometimesNeverOther
Any Special circumstances?

Parents divorcedChild adoptedJoint physical custodyChild adoptedOther
Health History:
Please Mark Appropriate Box(es) If Your Child/client Has Had Any of The Following:

Frequent Ear InfectionsHearing ProblemsSpeech TherapyAllergiesOccupational TherapyPhysical TherapyHead InjuryPrescription MedicationDevelopmental DelayPremature BirthHospitalizationEarly InterventionTubes In EarsBehaviour Therapy
Please Provide Further Explanations for Items Checked Above:
Is Your Child/client Diagnosed with Any Developmental or Sensory Disorders?

ADHDBlind/Visually ImpairedDyslexiaLanguage DisorderSocial Communication DisorderAnxietyCerebral PalsyDown’s SyndromeLearning DisorderStutteringAutismDeaf/Hard of HearingFragile X SyndromeOppositional Defiance DisorderArticulation DisorderDegenerative ConditionIntellectual DisabilitySensory Processing DisorderOther
Communication & Social Interaction
Does Your Child/client Play Well with Other Children/individuals?

YesNo
Which of the Following Apply to Your Child/Client?

CooperativeHyperactiveFrequent self-stimulation (spinning, hand flapping, etc)Easily frustrated/impulsiveMinimal eye contactAnxiousFrequent tantrumsPlays independently with othersInappropriate behaviorPoor understanding of dangerOther
Can Your Child/client Clearly and Appropriately Communicate the Following?

StatementsQuestionsAnswersWantsNeeds (ex: help)FeelingsDenial/ProtestsDiscomfort
About How Much of What Your Child/client Says Can You Understand?

Almost AllMostHalfQuarter or Less
About How Much Could a Stranger Understand?

Almost AllMostHalfQuarter or Less
What Is the Main Goal You Wish to Accomplish with Speech/Language Therapy?
List of medications
Do you have or ever had

DiabetesDislocationsPregnantRheumatoid arthritisSpinal traumaHeart complicationsPacemakerOsteoarthritisOsteoporosisHigh blood pressureJoint replacementsRecent nauseaBladder/Bowel issuesDizzinessCartilage injuriesAnkylosing spondylitisLigament injuriesImplantsUnexpected weight lossSpinal surgeryStrokesSpinal fractureAneurysmCancers
W: www.crosscarendis.com.au E:admin@crosscarendis.com.au

P: 02 8074 1888 M: 0416 204 394

By signing this form, I hereby give my consent for:

• The participant to receive Speech Pathology services from Cross Care and agree to pay all associated fees, including a Medicare Gap, for these services in accordance with Cross Care policies

• Cross Care to contact and share information and reports with educational staff, medical practitioners, specialists and health professionals involved in the participants care

• If the client is a child, I understand and agree that physical guidance contact between my child and their treating Speech Pathologist as necessary. I acknowledge that all care is taken whilst working with my child however physical contact may be required for guidance during therapy sessions, and that such contact will only be used to ensure the best outcome for the individual. I understand physical guidance may involve hand-over-hand prompting, guiding the individual into a seated position etc.

In addition, by signing below, I confirm that I understand and agree:

• To pay all fees and charges for the individuals Speech Pathology services on or before the date of the session

• If applicable, I am to be present for at least the first 5 minutes, and last 10 minutes, of my child’s session unless otherwise advised/agreed

• If applicable, I am responsible for supervising my child/ren whilst at Cross Care
The above must be at least 18 years of age, otherwise consent from a custodial parent is required to treat a minor. Your signature confirms that you have read and give consent to Cross Care Clinic Policy.
Signature

Clear
Date

MonthDayYear
Date
I blanks (parent/guardian name) consent to the above Terms and Conditions in relation to blank (child’s/clients name).
Should be Empty:

Speech Pathology Intake Form

Health History:

Communication & Social Interaction