CKSC Waitlist Intake Form

CKSC Waitlist Intake Form

Please complete to the best of your ability and we will contact you once we have an availability. If you require assistance to complete this form please contact us on (02)4204 9399 or southcoast@capablekids.com.au. *This form will take approximately 10minutes to complete*
Client Details
Name
First & Last Name
Date of Birth

DayMonthYear
Gender
Pronouns
Ethnicity/Nationality
Languages spoken at home
Do you/your child identify as Aboriginal or Torres Straight Islander?
Parent 1 Details
Parent Name
Occupation
Phone Number
Format: 0000000000.
E-mail
example@example.com
Preferred contact method:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent 2 details
Parent Name
First & Last Name
Occupation
Phone Number
Format: 0000000000.
E-mail
example@example.com
Preferred contact method:
Address - Same as Parent 1
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Living Situation

People living with child

Rows	Name	Relationship	DOB (Siblings)
1
2
3
4
5
6
7
8
9
10
11
12

Living Situation

Other
School
School/Preschool
Grade
Teacher
Days Attended
Services
Service required
Date Functional Capacity Assessment required by
Have you had an assessment completed for the service you are requesting in the past 12month eg. OT or Speech Assessment (completed by a qualified Speechie or OT)
Upload a copy or you previous Speech or OT Assessment Report here

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Please note: If your child has not had an assessment completed by a Speech Therapist or Occupational Therapist within the past 12 months, an updated assessment will be required before ongoing sessions can begin.

Once an ongoing appointment time becomes available, we will also arrange an initial assessment appointment for you at that time.
If you would like any further information on each of our services, please click on the following links

Speech Therapy

Occupational Therapy

Transdisciplinary (SPOT) Sessions - Speech & OT done together

Next Level - Independence in the community program

Assistive Technology - Equipment Trials (coming soon)

FCA - Functional Capacity Assessment (coming soon)
Diagnosis
What are your main Speech concerns? Please choose from the following:

Other
What are your main Occupational Therapy concerns? Please choose from the following:

Other
What would you like your child to achieve through therapy?
Child's strengths
Child's areas of support
Family History
Has any family member ever had any differences with learning, coordination, speech, language or general development?
Details
General Health
Has your child had any past or current significant health concerns (e.g. asthma, hospitalisations, seizures, chronic ear infections, surgeries)?
Health history

Rows	Date	Results
Hearing Tested
Vision Tested

Medication

List all medications currently being taken

Rows	Name	Reason	Duration
1
2
3
4

Allergies/ Anaphylaxis
List all applicable allergies/ anaphylaxis
Please give any further details required regarding the allergy/ anaphylaxis
Upload a copy of the ASCIA Action Plan

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Pregnancy
Length of pregnancy
Complications during pregnancy (Medications, accidents, illnesses, threatened miscarriage). If none please write NA
Birth
Birth Weight
APGAR Scores
Birth Complications (inductions, instruments, oxygen, humidicrib).If none please write NA
Feeding
How was your child fed from birth?

Other
Any feeding difficulties?

Development: Speech - If unsure or Not applicable write NA

Rows	Age
Vocalisations/ Noises
Babbled
First Words
Sentences (e.g 2 or more words together)

Development: Motor - If unsure or Not applicable write NA

Rows	Age
Sat alone
Crawled
Walked
Toilet trained - Day
Toilet trained - Night

Other people in your child's support team

Rows	Name	Contact Details	Are you currently attending
Paediatrician
Speech Pathologist
Occupational Therapist
Physiotherapist
Psychologist
Behavioural Therapist
Support Coordinator
Case Worker
Key Worker
Early Intervention Therapist
Other
Other

Funding
Funding options
Participant's NDIS Number
Plan Start Date

DayMonthYear
Date
Plan End Date

DayMonthYear
Date
Plan Management
Plan Manager details
Please attach a copy of your child's NDIS goals

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Availability
Please note our clinic is open 8am to 6pm Monday – Thursday and 8am to 4.30pm Friday.

Our therapists schedules vary between these times. The above availability will be met where applicable but should be given as a guide only and cannot be guaranteed.
If suitable, would you be interested in seeing an Allied Health Assistant – Supervised by our Senior Therapists? (an Allied Health Assistant is a therapist currently completing a Speech or Occupational Therapy degree at university)
IMPORTANT - Please note a holding fee of $95 will be payable within 48hrs of an appointment being booked for you. Your appointment will not be confirmed until this payment has been received in our clinic. This amount will be deducted from the total amount of your first appointment. Our fee schedule will be sent to you once an appointment is booked or alternatively you can contact us to request this earlier. (If you do not agree to this requirement - please contact our office to proceed)
Social media consent
Please note we aim to cover all children's faces in photos where possible, even if consent has been provided.

Form completed by

Rows	Name	Relationship to child	Date
1

Thank you for taking the time to complete the questionnaire.
Our senior therapists will review your answers to determine the best plan for your child
Should be Empty: