Wonders Allied Health Patient Intake Form

New Patient Intake Form (Waitlist)

Our therapists will review this form and we will contact you for an initial appointment to determine yours/your child's therapy needs
PATIENT DETAILS
Full Name

First NameLast Name
Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit year
Gender

Other
Phone Number
Please enter a valid phone number.Format: 0000 000 000.
Email Address
example@example.com
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Medicare Card Number
Medicare Reference (Number next to name)
Medicare Expiry

DayMonthYear
2 digit day, 2 digit month, 4 digit year
School/Daycare Details - Name, Address, Phone Number and Email Address:
PARENT/CARER DETAILS

This section is required to receive Medicare Rebates.
Full Name

First NameLast Name
Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit year
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: 0400 123 456.
Medicare Card Number
Medicare Reference (Number next to name)
Medicare Expiry

DayMonthYear
2 digit day, 2 digit month, 4 digit year
Gender

Other
Relationship to Child
Emergency Contact - Name, Phone Number & Email Address
THERAPY NEEDS

This section will help us determine what supports you are seeking, and how we can best help you
Which Services are you seeking with us?
Does patient have a diagnosis?
If you have any relevant previous reports, please attach to this section

Cancelof
SPEECH THERAPY QUESTIONNAIRE
Speech Issues

Other
Language Issues

Other
Literacy Issues

Other
Social Communication

Other
Nonverbal Communications and Behaviours

Other
Psychology Questionnaire
Please answer the following questions based on your subjective observations of your child over the past month
Does your child have any anxious presentations?(fidgetiness, temper tantrums, clinginess, crying with no apparent triggers, repeatedly asking certain questions):
Do they show any depressed mood symptoms? (Quieter than usual, social withdrawal, loss of interest in usual activities they used to enjoy):
Is there a history of trauma? (Clear past experience of physical, verbal, or sexual traumas, or domestic violence):
Are there communication and learning difficulties? (e.g. Stuttering, Not speaking or refusing to speak in certain situations, Concentration difficulties, Difficulty understanding social cues, Difficulty expressing thoughts and emotions [age appropriate], Difficulty engaging in learning tasks at school/child care/ other learning environments), Or difficulty learning new concepts?:
Is your child displaying behavioural difficulties? (Oppositional, Aggressiveness, Anti-social tendencies):
Do they experience sleep difficulties?:
Do they experience feeding/eating difficulties?:
Is there a history of parental trauma? (Clear past experience of physical, verbal or sexual traumas):
If yes to previous question, has this been treated?
Parents’ overall confidence in parenting the child:
Funding
Funding
If NDIS Plan Managed, please provide Plan Manager Name, Phone Number and Email Address
If NDIS funded, please provide plan start and finish dates
NDIS Number
If you have an NDIS plan or Medicare referral please upload to this section

Cancelof
GP Name and Contact Details
Paediatrician Name and Contact Details
Other Specialist Name and Contact Details
APPOINTMENT AVAILABILITY

What is your availability for appointments?
Appointment Day
Appointment Time
How did you hear about Wonders Allied Health?

Other
Signature
Name of Person Signing
Relationship to Patient
Date

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

New Patient Intake Form (Waitlist)

PATIENT DETAILS

PARENT/CARER DETAILS

THERAPY NEEDS

SPEECH THERAPY QUESTIONNAIRE

Psychology Questionnaire

Please answer the following questions based on your subjective observations of your child over the past month

Funding

APPOINTMENT AVAILABILITY