INITIAL Paediatric Participant Intake Form
This is a detailed intake form, so please allow 10 minutes to complete. Only answer questions that apply to your child.
1. Parent/Carer Details
PARENT/ CARER 1 DETAILS
Parent or Carer's 1 Full Name
*
First Name
Last Name
Mobile Phone Number
*
Please enter a valid phone number.
Main Email Address
*
example@gmail.com
PARENT/ CARER 2 DETAILS
Parent or Carer's 2 Full Name
First Name
Last Name
Mobile Phone Number
Please enter a valid phone number.
Main Email Address
example@gmail.com
How did you hear about Mobi Healthcare?
*
Please Select
GP
Paediatrician
Therapist
Client
Google
Facebook
Other
If other, please specify
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2.1 Participant's Details
Participant's Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Date
Date of Birth
Please select a day
1
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Day
Please select a month
January
February
March
April
May
June
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September
October
November
December
Month
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
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2015
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2012
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1929
1928
1927
1926
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1922
1921
1920
Year
Identifies as:
*
Please Select
Female
Male
Prefers not to specify
Residential Address
*
Street Address
Street Address Line 2
Suburb
State
Post Code
Your child's diagnosis or diagnoses. Please specify and include date of diagnosis (if applicable).
*
E.g. Spastic Diplegic Cerebral Palsy (GMFCS Level 3) - DD/MM/YYYY. Write N/A if not applicable
Additional diagnosis description
Does your child have a known degenerative or progressive health condition?
Yes
No
Paediatrician Name & Details
Parent/Carer's goals/ Primary Concerns
*
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2.2 Funding
What type of funding will you use?
*
NDIS
Private
NDIS Participant Number
*
NDIS Plan Dates
*
DD/MM/YYYY - DD/MM/YYYY
Category
*
Agency Managed
Plan Managed
Self Managed
Plan Manager's Details
*
First Name
Last Name
Plan Manager's Email
*
example@example.com
Plan Manager's Phone Number
Please enter a valid phone number (e.g., 04XX XXX XXX).
Do you have a support coordinator?
*
Yes
No
Support Coordinator's Name
*
First Name
Last Name
Support Coordinator's Email
*
example@example.com
Support Coordinator's Phone Number
Please enter a valid phone number (e.g., 04XX XXX XXX).
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2.3 Mobi Paediatric Therapy Services
Please select all service(s) you are requesting?
Physiotherapy
Occupational Therapy
Speech Pathology (Communication/ Feeding)
Hydrotherapy
Intensives
PHYSIOTHERAPY
What is your child's main form of mobility?
E.g. Being carried, crawling, walking with a walker, walking independently
What are your primary gross motor concerns/ goals for your child?
Therapy Frequency
Weekly
Biweekly
Any specific requests for times/ days
Preferred start date?
-
Day
-
Month
Year
Date
Are you interested in intensive therapy? (Intensive therapy involves a high frequency of therapy over a short duration of time. Based upon a client’s age, diagnosis, and goals, an intensive physiotherapy program involves 5 days a week for 2-3 weeks)
YES
NO
Any specific requests/ months wanting intensives?
OCCUPATIONAL THERAPY
Do you prefer your session to be in the:
Clinic
Community (Daycare, School, Home)
Please specify:
Here is the list of available OT services you can choose from. Please select the service(s) you are looking for.
Developmental therapy and assessments
School readiness
Sensory processing intervention
Assistive technology prescription
Fussy feeding intervention
Home modifications
Splinting / Casting
SPEECH THERAPY
What would you like your speech therapy session to focus on?
Communication
Feeding
Therapy Frequency
Weekly
Biweekly
Happy to be based on therapist recommendations
Any specific requests for times/ days
Preferred start date?
-
Day
-
Month
Year
Date
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3.1 General Information
Pregnancy and Birth History
Were there any complications, illnesses or stress during pregnancy?
Yes
No
If yes, please specify
Were there any complications, illnesses or stress during labour and delivery?
Yes
No
If yes, please specify
Weeks of gestation your child was born?
What was your child's birth weight?
Please specify the conditions of your child's birth
Vaginal
Forceps
Vacuum
C-section
Emergency
Planned
Premature
Postmature
Full Term
What is your child's birth order?
i.e. 1 = 1st child born, 2 = 2nd child born etc
What was your child's APGAR scores post birth?
Please provide score 1 min post birth and 5 minutes post birth
3. General Information
Medical History
Has your child experienced any major injuries or hospitalisations?
*
Yes
No
If yes, please specify
Current Medications
*
Please list
Does your child have allergies or anaphylaxis?
*
Yes
No
If yes, please specify what your child is allergic/ anaphylactic to
*
If yes, do you have an anaphylaxis management plan in place?
*
Yes
No
Does your child have a history of seizures?
*
Yes
No
If yes, please specify
i.e. type of seizures, frequency, duration, triggers, how they present
If yes, do you have a seizure management plan in place?
*
Yes
No
Does your child have a history of lung conditions (including asthma)?
*
Yes
No
If yes, please specify
If yes, do you have a asthma management plan in place?
*
Yes
No
Does your child have a history of heart problems?
*
Yes
No
If yes, please specify
Does your child have a history of kidney problems?
*
Yes
No
If yes, please specify
Does your child have history of bone density issues or history of fractures?
*
Yes
No
If yes, please specify
Does your child have a G-tube/ J-tube/ PEG?
*
Yes
No
If yes, please specify
Does your child have any history of concerns of scoliosis (curvature in the spine)?
*
Yes
No
If yes, please specify
Please specific degrees and location in spine if known.
Are your child's hips regularly monitored?
*
Yes
No
If yes, please specify when their most recent X-ray was
Is there any history of hip subluxation or dislocation?
*
Yes
No
If yes, please specify LEFT and RIGHT hip measurements
*
This may be indicated in a report as degrees or as the 'Migration Percentage' (MP)'
Please upload any reports or X-rays of your child's hips or scoliosis (if available)
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Has your child had their vision assessed?
Yes
No
If yes, please specify by what profession and when:
Does your child wear glasses?
Yes
No
If yes, what do they assist with?
Does your child have a history of ear infections?
Yes
No
If yes, please specify?
Has your child had their hearing tested?
Yes
No
If yes, please specify when and what the results were:
Does your child wear a hearing aid?
Yes
No
Current Height
*
Current Weight
*
Does your child wear specific supportive shoes?
Yes
No
Does your child currently have AFOs or other orthotics?
Yes
No
If yes, please specify the type of AFO or orthotic
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4. Social History
Who does your child live at home with?
*
Does your child have siblings? (Please list their ages)
*
Types of residence:
*
(E.g. Apartment, single storey house, double storey house with stairs, is the home accessible?)
Preschool or School they attend?
*
Please include: number of days and type of school
Supports:
Formal and Informal. How often?
Extra-curricular activities:
What currently motivates your child?
*
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5. Therapy History
Please select or specify the therapy your child is currently attending
Physiotherapy
Occupational Therapy
Speech Therapy (Communication/Feeding)
Other
5.1 PHYSIOTHERAPY
Current Physiotherapy Clinic
Session duration
Session frequency
i.e. weekly, fortnightly, monthly
What has your child been working on in these sessions?
5.2 OCCUPATIONAL THERAPY
Current Occupational Therapy Clinic
Session duration
Session frequency
i.e. weekly, fortnightly, monthly
What has your child been working on in these sessions?
5.3 SPEECH THERAPY
Current Speech Therapy Clinic
Session duration
Session frequency
i.e. weekly, fortnightly, monthly
What has your child been working on in these sessions?
5.4 OTHER THERAPIES
Please list any other therapies you child is currently participating in
E.g. Hydrotherapy, Music Therapy etc. Please outline the frequency of these sessions.
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6. Milestone History
Tell us the approximate age your child achieved the following skills
Rolling
Belly / Army Crawling
Sitting
Crawling
Standing with assistance
Standing independently
Cruising (Take side steps along furniture/ objects)
Walking
First words
Talking
Jumping
Hopping
Running
Hopping
Skipping
What is your child's main form of mobility?
E.g. Being carried, crawling, walking with a walker, walking independently
What are your primary gross motor concerns/ goals for your child?
7. Movement Skills
Does your child become overly excited over movement activities?
Yes
No
If yes, please specify
Does your child like to be wrapped tightly in a sheet/ blanket or seeks tight spaces?
Yes
No
If yes, please specify
Does your child display the following movement difficulties? Tick all that applies to your child.
Avoids activities where feet leave the ground
Avoid activities/ fears activities requiring balance
Avoids age appropriate gross motor activities
Excessive dizziness from swinging, spinning or riding a car
Stamps/ slaps feet on ground when walking
Loses balance/ trips easily or frequently
Resists having head tilted backwards
Drags feet or poor heel-toe pattern when walking
Unable to reciprocate feet on stairs
Fears falling when no real danger exists
Drags hand or bangs object along wall when walking
Difficulty moving from one floor surface to another
Fearful of being tossed in the air or turned upside down
Lethargic or inactive
Confuses left and right
Holds head upright when leaning or being leaned over
Difficulty moving between rooms
Dislikes inversion (being upside down)
Sets jaw or locks major joints/ arms/ legs for stability when applying effort
Lacks body awareness of where body is in space (poor body scheme awareness)
Poor sense of direction
Limited rotation or movement around pelvis/ shoulder girdles
Moves quick with bursts of activities rather than sustained effort
Dislikes being moved
Seems weaker or tires more easily than peers
Poor coordination or sense of rhythm
Please add any other comments you would like to include about your child's movement patterns
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6. Feeding
Was your child breastfed as an infant?
Yes
No
If yes, please specify how long your child was breastfed for
If your child was bottle fed, were there any difficulties or concerns?
Yes
No
If yes, please specify
Did your child have a strong suck reflex as a child?
Yes
No
If no, please specify
Did your child frequently spit up as an infant or have reflux?
Yes
No
If yes, please specify
Did your child have problems with appetite or weight gain as an infant?
Yes
No
If yes, please specify
Did your child have respiratory problems as an infant?
Yes
No
If yes, please specify
How is your child currently fed?
Tube Fed
Orally fed by care-giver
Self-feeding
Which behaviours are noted during feeding?
Vomits during feeding
Holds food in his/ her mouth
Tires easily
Poor appetite
Refuses bites offered
Chews but does not swallow
Stressful for child or parent
Other
Please specify
Does your child attempt to eat unusual, noxious or inedible substances or place in mouth?
Yes
No
If yes, please specify
Does your child have a history of:
Gagging
Choking
Pneumonia
Drooling
Constipation
Aspiration
Difficulty overcoming colds
Inability to gain weight
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7. Social Interaction and Communication
If yes, is it directed towards themselves or others?
Please specify - Biting, pinching, kicking, hitting, other etc
Does your child exhibit aggressive behaviour?
*
Yes
No
Does your child exhibit tantrums?
*
Yes
No
If yes, please specify frequency, triggers, average length of tantrum, and effective strategies
Is your child easily frustrated, anxious or overwhelmed?
*
Yes
No
If yes, please specify
If your child uses atypical repetitive behaviour, which behaviours are demonstrated?
Hand flapping
Rocking
Head banging
Jumping
Smelling
Breath holding
Humming
Self-talk
Biting
Mouthing objects
Visual fixing
Spinning
Teeth grinding
Other
Is your child willing to try new activities?
Yes
No
Does your child struggle when there is excessive auditory input in their environment?
Yes
No
If yes, how does your child react?
Does your child have difficulty meeting new people?
Yes
No
If yes, how does your child react?
Does your child struggle to communicate their own needs?
Yes
No
If yes, please specify
How do you communicate with your child?
*
E.g., verbally, using gestures/signs, writing, AAC
How does your child communicate with you?
*
E.g., verbally, using gestures/signs, writing, AAC
Is your child able to follow simple directions?
*
Yes
No
Does your child use:
A communication board or book
Picture Exchange Communication System (PECS)
Electronic device E.g. BIGmack Switch, Proloquo2go, Dynavox, PODD
How often does your child make eye contact during conversation?
Less than 25% of the time
25% of the time
50% of the time
75% of the time
100% of the time
How often does your orient to his/ her name being called?
Less than 25% of the time
25% of the time
50% of the time
75% of the time
100% of the time
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10. Play Skills
How long is your child able to play alone?
1-2 minutes
2-5 minutes
5-10 minutes
10-30 minutes
30+ minutes
What are your child's preferred play activities?
Does your child struggle playing with children?
No
Yes, struggles with parallel play (playing alongside other children)
Yes, struggles with interactive play (playing with other children)
Yes, struggles with structured play group
Yes, struggles with making friends
Please add any other comments you like to include about your child's social interactions
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8. Aspirations and Expectations
Please tell us your overall primary concerns
*
Please explain what you would like to accomplish with us and what information you would like to receive
Please list your child's short term goals
Please list your child's long term goals
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9. NDIS Plan Goals
Please copy and paste your NDIS Goals here
Goal 1
Goal 2
Goal 3
Goal 4
Goal 5
Goal 6
Goal 7
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9. Attach your files
Please upload a copy of your Short and Long Term Goals in your NDIS Plan
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Please upload any reports or previous assessments that will assist with your care here at Mobi Healthcare.
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Please upload any management plans for i.e. seizures, anaphylaxis, asthma, behavioural
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Date
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