Signing up to Whiz Kids

Signing up to Whiz Kids

Thanks for choosing Whiz Kids Therapy. This form gives us what we need to plan the right assessment for your child. It takes about 10 minutes. We'll let you in a few days about our availability.
Parent and Child Details
Parent/Guardian full name

First NameLast Name
Child's full name

First NameLast Name
Child's date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email
example@example.com
Mobile
Please enter a valid phone number.Format: 000)-000-0000.
Preferred way to communicate with you

Other
Funding type

Other
Is your child at one of our partner schools?
School/childcare name and teacher's name and email address
May we liaise with the teacher/school?
Concerns and History
What are you concerned about?

Other
Tell us more — what do you notice, when did it start, what worries you most?
Your own words are fine: descriptions, examples or reactions are welcome
What does the school/teacher say (if anything)?
Any of the following apply?
Has your child had speech pathology assessments or therapy before?
If yes, please briefly summarise the outcome of the speech pathology support, and include the practitioner’s name or company.
Has your child had their hearing checked before?
If yes, please briefly summarise the outcome of the hearing test, and include the practitioner’s name or company.
Has your child had any other assessments, such as psychology, occupational therapy, or paediatrics?
If yes, please briefly summarise the outcome of the psychology support, and include the practitioner’s name or company.
If occupational therapy was involved, briefly summarise the treating professional and outcome/diagnosis.
If paediatrics was involved, briefly summarise the treating professional and outcome/diagnosis.
Early history (helps us understand your child's presentation)
Birth and first three years — anything notable? (pregnancy/birth, milestones, ear infections, talking late, feeding)
Languages spoken at home
Practical Details and Consent
Where could sessions happen?
Best times generally
Anything else Alex should know? (interests, motivators, siblings, custody/consent arrangements)
How did you hear about us?
Consent and service understanding
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Signing up to Whiz Kids

Parent and Child Details

Concerns and History

Early history (helps us understand your child's presentation)

Practical Details and Consent