Section A: Child's Details
Participant receiving therapy
Child's Name
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Child's most regular Household Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child's Contact Number (If child is able to make their own decisions)
Please enter a valid phone number.
Format: (000) 000-0000.
Child's NDIS Reference Number
Child's NDIS Plan Date Start
-
Month
-
Day
Year
Date
Child's NDIS Plan Date End
-
Month
-
Day
Year
Date
Who lives with the child on a regular basis?
*
Does your child have any of the following difficulties
*
Mobility
Fine Motor Skills
Gross Motor Skills
Anxiety
Mental Health
Depression
Communication difficulties
Social Skills
Diet
Feeding
Play Skills
Behaviour difficulties
Other
If you chose 'Other' in the above question, please specify:
Does your child have difficulty engaging with other people?
*
Difficulty engaging with immediate family members (e.g., siblings)
Difficulty engaging with extended family members (e.g., cousins)
Difficulty engaging with adults
Difficulty engaging with new adults
Difficulty engaging with children
Difficulty engaging with new children
My child does not seem to have difficulty with engaging with other people
What educational institute does your child attend? (E.g., name of preschool, school etc.) Please put N/A if your child does not yet attend.
*
What year is your child in?
Has there been any confirmed diagnosis for your child?
*
Does your child receive additional support at their Educational Institution?
Yes - simplified work or extensions in class
Yes - support class
No
Has your child suffered any recent significant Medical History? (If so, please specify)
Does your child take any regular medication? (if so, please specify)
What is your child's cultural background? (Please specify if there are any religious or cultural considerations that should be known prior to commencing therapy).
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Section B: Parent Details and/or Referrer Details
Referrer represents the person that coordinates your child's services.
What best represents you?
*
Mother
Support Coordinator
Case Manager
Father
Plan Manager
Sibiling
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you want to receive educational resources and newsletter?
Yes
No
Only when specific to my child
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Section C: Reason for Referral
Please address any Assessments that have been conducted
Has your child had an Allied Health Assessment in the past 12 months?
*
Speech Therapy
OT
Psychology
Behaviour Therapy
Physiotherapy
Exercise Physiology
Dietician
Podiatry
Which Allied Health Service do you have concern in for your child?
Speech
Mobility
Hand writing
Walking
Feeding
Behaviour/Behaviour triggers
Other
Please specify any more general concerns regarding your child's development:
*
What are the main concerns in terms of your child's Speech and Language?
*
Has there been concerns raised by an educator or unfamiliar communication partner regarding your child's communication?
*
Does your child have any specific difficulty to feeding or swallowing? Has has there been any recent choking accident?
*
Does your child have any behavioural triggers? (If so, please also specify the behaviours associated)
*
What personal skills is your child independent with? (E.g., Self feeding, toileting etc.) You may also specify specific difficulties your child may have.
*
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Section D: Services Seeking
Please specify if your child is currently seeing other Allied Practitioners, or if you are interested in receiving additional Allied Health Services. If you could also please send through any recent relevant reports to ensure a full visualisation of your child's skills.
Occupational Therapy
Seeking for Ongoing OT Therapy
Seeking for Initial OT Assessment
Currently undergoing regular OT Therapy
Currently undergoing OT Initial Assessment
Previous OT Therapy
Unsure of what Occupational Therapy consists of
My child does not require this service
Speech Therapy
Seeking for Ongoing Speech Therapy
Seeking for Initial Speech Therapy Assessment
Currently undergoing regular Speech Therapy
Currently undergoing Speech Therapy Initial Assessment
Previous Speech Therapy
Unsure of what Speech Therapy consists of
My child does not require this service
Psychology
Seeking for Ongoing Psych Therapy
Seeking for Initial Psych Assessment
Currently undergoing regular Psych Therapy
Currently undergoing Psych Initial Assessment
Previous Psych Therapy
Unsure of what Psychology consists of
My child does not require this service
Exercise Physiology/Physiotherapy
Seeking for Ongoing Exercise Physiology/Physiotherapy
Seeking for Initial Exercise Physiology/Physiotherapy Assessment
Currently undergoing regular Exercise Physiology/Physiotherapy Therapy
Currently undergoing Exercise Physiology/Physiotherapy Initial Assessment
Previous Exercise Physiology/Physiotherapy Therapy
Unsure of what Exercise Physiology/Physiotherapy consists of
My child does not require this service
Behaviour Therapy
Seeking for Ongoing Behaviour Therapy
Seeking for Initial Behaviour Therapy Assessment
Currently undergoing regular Behaviour Therapy
Currently undergoing Behaviour Therapy Initial Assessment
Previous Behaviour Therapy
Unsure of what Behaviour Therapy consists of
My child does not require this service
I have a BCBA Practitioner
I am looking for a BCBA Practitioner also
If you consent for interdisciplinary discussion on your child's progress (Discussion between your child's Allied Health Team). Please specify their: Discipline, Company, Name and Contact Details below:
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Section E: Goals
What would you like Allied Health Therapy to target?
What specific skills or goals in terms of child development would you like your child to improve?
What are your child's strengths and interests? You may also specify what you might think would work as a motivator in Allied Health Therapy.
What are long term Development goals you may want your child to achieve, or your child aims to achieve (E.g., transitioning to mainstream classroom, entering the workforce etc.)
When would you prefer to undergo a review of your child's progress?
Every 3 months, a progress report
Every 6 months, a progress report
Every 12 months, a comprehensive assessment report
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Section F: Payment and Account Details
Invoicing
How is your child's account managed?
*
NDIA Agency Managed
Plan-Managed
Self-Managed
Medicare
Private
Who will receive the invoice for your child's Speech Services?
*
What Organisation manages this account (if applicable)?
Support Coordinator Name (if applicable)?
Organisation Contact Details (if applicable)?
If you have any further information you would like to supply, please feel free to do this in this space:
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