Neuro - Habilitation Intake and Goals Form

Neuro - Habilitation Intake and Goals Form

Kia Kaha Neuro - Habilitation Foundation
Parent/Caregiver Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Additional Parent/Caregiver Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child's Details

First NameLast Name
Date of Birth

DayMonthYear
Gender
Tell us about your Child.
What are some of the cool things your child is good at?
What activities does your child love to do? What motivates your child?
Medical History

Primary DiagnosisOther
Date of Diagnosis

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Additional Diagnoses/ Diagnosis Description
My child's diagnosis is considered a progressive or degenerative condition.
My child presents with fatigue concerns
History of medical and/or surgical procedures (please list with dates):
History of major hospitalisations (please list with dates):
Current weight (in kg)
Current height (in cm)
Does your child have known allergies?
List allergies and detail allergy management plan:
Does your child have a history of or current seizures? *
Are your child's seizures controlled?
What might trigger your child's seizure(s)?
How long do your child's seizures typically last?
Describe seizure type(s) and detail seizure management plan:
Does your child have a history of or current heart problems/hypertension?
Has your child now or ever had a diagnosis of decreased bone density?
Are your child's hips regularly monitored?

Other
Any history of hip subluxation/dislocation?
Developmental Skills
I would like my child to work on gross motor skills.

Gross Motor Skills

Rows	With an assistive device	With a lot of help	With a little help	Independently
Hold their head steady
Roll
Reach
Sit
Crawl
Pull to stand
Stand
Cruise
Take steps
Walk
Run, Jump, Hop

Gross Motor Comments and Goals
Include here which adaptive device your child may use as well as goals you would like to work on.
I would like my child to work on fine motor, play, and/or self-help skills.

Fine Motor/Activity of Daily Living Skills:

Rows	With only one hand	With a lot of help	With a little help	Independently
Hold object with both hands.
Hold objects functionally.
Brings objects to mouth.
Uses utensils for eating.
Helps with dressing.

Fine Motor/ADL Skills - Comments and Goals
When your child gets upset, what helps calm them down?
Select all that apply.
What best describes your current therapy or referral situation? This helps us understand your whānau's journey, triage intake, and assist with relevant funding/grant pathways.
I give permission for my child to be filmed and photographed to be used as part of his/her assessment plan/individual plan (centre use only)
I give permission for my child to be filmed and photographed to be used on Kia Kaha Foundation's Website/Facebook page/Instagram Page/Pamphlet
Should be Empty: