Child contact & background information form

External Professional Information
Paediatrician*
GP/Child's doctor*
Are there additional professional details you would like to add? (i.e. psychologist, speech pathologist, occupational therapist etc)*

YesNo
Do you give consent for our Allied Health professional to discuss your child's development with each of these professionals?*

YesNo
Current Educational Setting
Does your child attend a kinder/childcare/pre-school/school etc?*

YesNo
Please list the educational setting (childcare/kindergarten/school) that your child attended in the last 12 months:*
Contact details for current educational setting*
Service History
Please list any current and prior intervention services that your child receives (e.g. Behavioural Intervention, Speech Therapy, Occupational Therapy, etc.):

	Yes	Relationship
Autism / ASD / Asperger’s Disorder / Pervasive Developmental Disorder
Birth defect
Cerebral Palsy
Physical disability
Severe head injury
Chromosomal / genetic disorder
Obsessive Compulsive Disorder
Anxiety
Depression
Bipolar / manic-depressive disorder
Tics / Tourette's syndrome
Schizophrenia
Other mental illness
Childhood behaviour disorder (Oppositional Defiant Disorder/Conduct Disorder/ADHD)
Intellectual disability
Reading problem
Speech / language delay
Other learning disability
Seizures / epilepsy
Alzheimer's disease
Parkinson's disease
Food allergies
Other - please specify
None of the above apply

Contact & Background Information