New Client Intake Form

New Client Intake Form
Client's Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Gender: How do you identify?*

MaleFemaleTransgenderNon-binaryAgenderGender fluidPrefer to self-identify
Pronouns*
e.g., she/her/they/them/he/him
Parent/Guardian 1
Name   First Name   Last Name
Relationship to client
Email   Email
Phone Phone Number
Address   Street Address      City
Parent/Guardian 2
Name   First Name   Last Name
Relationship to client   Type a label
Email   Email
Phone Phone Number
Address   Street Address      City
Language(s) spoken at home*
Interpreter required?*

YesNo
Name of current Daycare / Kindergarten / School*
Client's year level at school. Please include teachers contact details if applicable.*
What are the client's strengths and interests? Where is the client happiest?*
Does the client have a formal diagnosis? (If yes, please provide details)*
Have any specialists assessed or treated the client in the past?*

NoSpeech PathologyPsychologyOccupational TherapyPhysiotherapyPaediatricianENTDieticianMusic TherapyOther
What areas do you feel the client needs assistance with?*

Speech Sounds/Clarity of SpeechLanguage: UnderstandingLanguage: ExpressingLiteracy: Spelling, reading, writing and comprehensionEmotional RegulationUnderstanding and Building Relationships/FriendshipsSelf-Advocacy Skills: Understanding and Expressing NeedsExploring Identity/Understanding Diagnosis/esProblem SolvingStuttering/Fluency of SpeechTransitions and Routines
When did you first notice any of the above difficulties/differences?
Is there a family history of speech and/or language difficulties?*
Has the client had any surgeries? (Please list what and when e.g. tonsillectomy/adenoidectomy)*
Does the client have any allergies?*
Is the client currently taking any medication?*
Has the client had their hearing assessed by an audiologist? (If yes, please list the date tested and results)*
Has the client had a history of ear infections?*

YesNo
Does the client have any vision concerns?*
Is the client bothered by any of the following?*

Loud or unexpected noisesHaving dirty or sticky handsBeing barefoot in the grassHaving hair or nails cutCertain food texturesBright lightsBeing upside-downBeing in loud or crowded placesTight-fitted clothes (e.g. hat, jeans or coat)Changes in routineNone of the aboveOther
If 'Other', please specify
Does the client exhibit any of these behaviours?*

Seeks a high amount of movement (e.g. likes to jump, climb and play rough more than others his/her/their age)Strong preference for spinning, swinging, rolling and/or flapping handsTouches objects or people excessivelyTakes bold risks during play/has no fearLikes TV/music at high volumesFixates visually on objects (e.g. lines up toys or other objects and visually scans them repeatedly)Prefers foods with strong flavours (e.g. pickle, lemon, chilli)Licks or chews on non-food itemsMakes odd noises just to hear themIs nearly impossible to take to the movies, or places that don't allow for much movement or noiseNone of the aboveOther
If 'Other', please specify
What do you worry about regarding the client's development?*
Appointment Location Preference*

Home VisitSchool VisitTelehealth
Is there an NDIS plan in place? (If so, we are required to complete a Service Agreement between the client and our practice)*

YesNo
If the client is an NDIS participant:
NDIS Number:
NDIS Start Date:
NDIS End Date:
Is there anything else you would like to share regarding the concerns and priorities you have for the client?
Should be Empty:

New Client Intake Form

Parent/Guardian 1

Parent/Guardian 2