Parent Intake Form
Name of Child
D.O.B.
School
Grade
Parent / Guardian Name
First Name
Last Name
Parent / Guardian Contact Number
Email
example@example.com
How did you find out about our service?
Child Resides with:
Both Parents
Father
Mother
Guardian
Parents Marital Status:
Married
De-facto
Separated
Divorced
Widowed
Are there any court orders or restriction regarding care or contact with the child?
Sibling 1:
Name and Age
Sibling 2:
Name and Age
Sibling 3:
Name and Age
Sibling 4:
Name and Age
Ethnicity / Primary language spoken at home
Is your child currently accessing any other allied health services?
Occupational Therapy
Speech Pathology
Psychology
Other
Primary Concern: What is currently the most significant concern for your child
Describe your child's early motor development
Concerns regarding developmental stages - sitting, walking, talking
Describe your child's language development
Speech onset, pronunciation, ability to understand and express language
Previous Diagnoses and Assessments
Language, Occupational Therapy, Psychometric, etc
Current Medication
Prescription, supplements, vitamins, etc.
Education and school performance
Academic performance, main concerns regarding their learning
Describe your child's concentration
Ability to focus and sustain attention
Behaviour and Compliance
Concerns regarding your child's behaviour, willingness to follow instructions, etc.
Friendship and Social Skills
Ability to engage appropriately with peers, problems and points of conflict
Concerns regarding mood, anxiety, self-esteem, odd behaviours, etc
Any other psychological concerns observed
Other:
Additional concerns that have not been reported earlier in the form
Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: