• Early Autism Initiative (EAI)

    Early Autism Initiative (EAI)

  • Welcome to the Early Autism Initiative (EAI) Pathway eligibility form

    This form is the first step in assessing whether your child meets the clinical criteria for this pathway.

    It allows our team to:
    • Review your child’s developmental profile
    • Confirm suitability for this assessment model
    • Ensure appropriate and evidence-based care

    Time required: approximately 20-30 minutes
    (Completing all sections carefully is essential for accurate screening.)

    You can save and return to this form at any time.

    For best performance:
    Please complete on a PC or laptop using Google Chrome with cookies enabled.

  • About this pathway

    The EAI is a fully funded, pro-bono assessment only pathway with limited places, designed for children who meet specific clinical criteria.

     

    • There is no cost to your family for the assessment itself
    • As part of the process, your child may be referred to partner services including audiology services, at no out-of-pocket cost
    • A GP referral addressed to our Developmental Paediatrician is required prior to assessment, to support continuinty of care. Please note that obtaining a GP referral may incur a consultation fee depending on your GP's billing practices
    • This pathway provides assessment only and does not include ongoing therapeutic support of follow-up care at Wild Child Paediatrics
    • All families will recieve a written report regardless of the assessment outcome
    • Assessment does not guarantee a diagnosis
    • Where appropriate, families may be linked with post-diagnosis support partners following assessment at no out-of-pocket cost.
    • De-identified information from this pathway may be used for clinical audit and research purposes to improve our services and contribute to the evidence base for early autism assessments.

     

    After you submit this form

    Your information will be securely stored and reviewed as part of our quaterly clinical intake process. Submission of this form does not guarantee a place in the EAI pathway.

    All applications are carefully reviewed by our team, and families will only be contacted if their child meets the criteria to proceed to the next stage. Due to the limited number of places available, we are unable to offer a position to every family.

    If you would like your information removed at any time please contact us at: eai@wildchildpaediatrics.com

     

  • I/We confirm that by proceeding, we agree that:*
  • Getting Started

  • Who hold's parental responsibility for your child?*
  • Can your child walk independently?*
  • Thank You for Completing the Questionnaire

     

    Thank you for completing the screening for our Early Autism Initiative.

    Based on the information provided, your child doesn’t currently meet the inclusion criteria for this funded pathway.

    The Early Autism Initiative is designed for children who meet specific eligibility requirements.

    This doesn’t mean your concerns aren’t important, or that your child wouldn’t benefit from assessment and support. If you would like to proceed via our private pathway, you are very welcome to join our waitlist HERE.

     We look forward to supporting your family.

    Please click HERE to close this form.

  • Current Date
     - -
  • Thank You for Completing the Questionnaire

     

    Thank you for completing the screening for our Early Autism Initiative.

    Based on the information provided, your child doesn’t currently meet the inclusion criteria for this funded pathway.

    The Early Autism Initiative is designed for children who meet specific eligibility requirements.

    This doesn’t mean your concerns aren’t important, or that your child wouldn’t benefit from assessment and support. If you would like to proceed via our private pathway, you are very welcome to join our waitlist HERE.

     We look forward to supporting your family.

    Please click HERE to close this form.

  • Is your main concern Autism?*
  •  

    Thank You for Completing the Questionnaire

     

    Thank you for completing the screening for our Early Autism Initiative.

    Based on the information provided, your child doesn’t currently meet the inclusion criteria for this funded pathway.

    The Early Autism Initiative is designed for children who meet specific eligibility requirements.

    This doesn’t mean your concerns aren’t important, or that your child wouldn’t benefit from assessment and support. If you would like to proceed via our private pathway, you are very welcome to join our waitlist HERE.

     We look forward to supporting your family.

    Please click HERE to close this form.

     

     

  • Are these concerns present in more than one setting (home and childcare/school)?*
  •  

    Thank You for Completing the Questionnaire

     

    Thank you for completing the screening for our Early Autism Initiative.

    Based on the information provided, your child doesn’t currently meet the inclusion criteria for this funded pathway.

    The Early Autism Initiative is designed for children who meet specific eligibility requirements.

    This doesn’t mean your concerns aren’t important, or that your child wouldn’t benefit from assessment and support. If you would like to proceed via our private pathway, you are very welcome to join our waitlist HERE.

     We look forward to supporting your family.

    Please click HERE to close this form.

     

     

  • Has your child had a previous Autism assessment?*
  •  

    Thank You for Completing the Questionnaire

     

    Thank you for completing the screening for our Early Autism Initiative.

    Based on the information provided, your child doesn’t currently meet the inclusion criteria for this funded pathway.

    The Early Autism Initiative is designed for children who meet specific eligibility requirements.

    This doesn’t mean your concerns aren’t important, or that your child wouldn’t benefit from assessment and support. If you would like to proceed via our private pathway, you are very welcome to join our waitlist HERE.

     We look forward to supporting your family.

    Please click HERE to close this form.

     

     

  • Does your child have a significant medical or genetic condition that is impacting their development?*
  •  

    Thank You for Completing the Questionnaire

     

    Thank you for completing the screening for our Early Autism Initiative.

    Based on the information provided, your child doesn’t currently meet the inclusion criteria for this funded pathway.

    The Early Autism Initiative is designed for children who meet specific eligibility requirements.

    This doesn’t mean your concerns aren’t important, or that your child wouldn’t benefit from assessment and support. If you would like to proceed via our private pathway, you are very welcome to join our waitlist HERE.

     We look forward to supporting your family.

    Please click HERE to close this form.

     

     

  • Is there current child protection involvement or an acute mental health crisis?*
  •  

    Thank You for Completing the Questionnaire

     

    Thank you for completing the screening for our Early Autism Initiative.

    Based on the information provided, your child doesn’t currently meet the inclusion criteria for this funded pathway.

    The Early Autism Initiative is designed for children who meet specific eligibility requirements.

    This doesn’t mean your concerns aren’t important, or that your child wouldn’t benefit from assessment and support. If you would like to proceed via our private pathway, you are very welcome to join our waitlist HERE.

     We look forward to supporting your family.

    Please click HERE to close this form.

     

     

  • Has your child experienced any significant trauma or highly distressing events that are still affecting them day-to-day?*
  •  

    Thank You for Completing the Questionnaire

     

    Thank you for completing the screening for our Early Autism Initiative.

    Based on the information provided, your child doesn’t currently meet the inclusion criteria for this funded pathway.

    The Early Autism Initiative is designed for children who meet specific eligibility requirements.

    This doesn’t mean your concerns aren’t important, or that your child wouldn’t benefit from assessment and support. If you would like to proceed via our private pathway, you are very welcome to join our waitlist HERE.

     We look forward to supporting your family.

    Please click HERE to close this form.

     

     

  • Social Interaction and Communication

    MCHAT-R
  • 1. Does your child enjoy being swung, bounced on your knee, etc.?*
  • 2. Does your child take an interest in other children?*
  • 3. Does your child like climbing on things, such as furniture, playground equipment, or stairs?*
  • 4. Does your child enjoy playing peek-a-boo or hide-and-seek?*
  • 5. Does your child ever use their index finger to point, to ask for something?*
  • 6. Does your child ever bring objects to show you?*
  • 7. Does your child ever try to attract your attention to something by making sounds?*
  • 8. Does your child ever try to copy your facial expressions?*
  • 9. Does your child respond to their name when called?*
  • 10. If you point at something across the room, does your child look at it?*
  • 11. Does your child ever pretend to talk on the phone or take messages?*
  • 12. Does your child ever pretend to drink from a cup, eat from a spoon, etc.?*
  • 13. Does your child try to get you to watch them?*
  • 14. Does your child respond to other children's emotions?*
  • 15. Does your child use simple gestures, like waving goodbye?*
  • 16. Does your child enjoy playing with toys?*
  • 17. Does your child look you in the eye for more than a second?*
  • 18. Does your child smile in response to your face or your smile?*
  • 19. Does your child imitate you?*
  • 20. Does your child respond when you smile at them?*
  • Thank You for Completing the Questionnaire

     

    Thank you for completing the screening for our Early Autism Initiative.

    Based on the information provided, your child doesn’t currently meet the inclusion criteria for this funded pathway.

    The Early Autism Initiative is designed for children who meet specific eligibility requirements.

    This doesn’t mean your concerns aren’t important, or that your child wouldn’t benefit from assessment and support. If you would like to proceed via our private pathway, you are very welcome to join our waitlist HERE.

     We look forward to supporting your family.

    Please click HERE to close this form.

  • Social Interaction and Communication

    SRS-2 Preschooler
  • Rows
  • Thank You for Completing the Questionnaire

     

    Thank you for completing the screening for our Early Autism Initiative.

    Based on the information provided, your child doesn’t currently meet the inclusion criteria for this funded pathway.

    The Early Autism Initiative is designed for children who meet specific eligibility requirements.

    This doesn’t mean your concerns aren’t important, or that your child wouldn’t benefit from assessment and support. If you would like to proceed via our private pathway, you are very welcome to join our waitlist HERE.

     We look forward to supporting your family.

    Please click HERE to close this form.

  • SRS-2 Results

  • Child's Details

  • Sex (as on birth certificate):*
  • Ethnicity:*
  • Legal Guardian Details

  • Date of Birth (dd/mm/yyyy)*
     - -
  • Relationship to Child*
  • Address as above:*
  • Format: 0000 000 000.
  • Are there any Court Orders in place?*
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  • PRIVACY ACT 1988

             PATIENT/PARENTAL CONSENT TO COLLECT & DISCLOSE INFORMATION

    The Privacy Act 1988 requires medical practitioners to obtain consent from their patients to collect, use and disclose that patient’s personal information.

    Collection

    This means we will collect information that is necessary to provide proper advice and treatment. Such necessary information may include;-

    • Full and detailed medical history
    • Family medical history
    • Ethnicity
    • Contact details
    • Medicare/private health fund details
    • Genetic information
    • Billing/account details

    The information will normally be collected directly from you and/or your child. There may be occasions when we will need to obtain information from other sources.

    For example;-

    • Other medical practitioners, such as GP’s and specialists
    • Other health care providers such as physiotherapists, occupational therapists, psychologists, pharmacists, dentists, nurses
    • Day care, teachers, child carers
    • Hospital and Day Units

    Both our practice staff and the medical practitioners may participate in the collection of this information.

    In emergency situations, we may need to collect personal information from relatives or any other resources where we are unable to obtain your prior express consent.

    Use & Disclosure

    With your consent, the practice staff will use and disclose you/your child’s information for purposes such as;-

    • Providing advice to the referring doctor
    • Referral to another medical practitioner or health care provider
    • Sending specimens such as blood samples for analysis
    • Referral to a hospital for treatment and/or advice
    • Advice on treatment options
    • To prevent or lessen a serious threat to an individual’s life, health or safety
    • Account keeping and billing purposes
    • Where legally required to do so such as producing records to court, or the notification of diagnosis of certain communicable diseases.

    Access to any information or records can be denied where;-

    • To provide access would create a serious threat to life or health
    • There is a legal impediment to access
    • The access would unreasonably impact on the privacy of another
    • Your request is frivolous
    • The information relates to anticipated or actual legal proceedings and you would not be entitled to access the information in those proceedings
    • In the interest of national security

    A request for medical information may be denied at the discretion of the treating doctor.

    All requests for information must be made in writing with permission from both parents in shared custody arrangements, as well as the patient if the patient is aged 12 years and over.

    An administration fee may be charged for the time involved in processing your request. Where you dispute the accuracy of the information we have recorded, you are entitled to place in writing your requested correction which will be kept with the patient’s records. An amended document may be provided however, we will not erase the original record.

    Any request for medical information may be denied at any time at the discretion of the treating doctor.

    For further information please see our Privacy Policy.

    Consent

    I provide my consent for this medical practice by all staff and doctors to collect, use and disclose my/my child’s personal information as outlined above.

    I understand that I am entitled to access my child’s records which must be made in writing with permission from both parents in a shared care custody arrangement, as well as the patient if aged 12 years and over, except where access would be denied as outlined above.

    I understand that I may withdraw my consent at any time and that this must be in writing with permission from both parents in a shared care custody arrangement, as well as the patient if aged 12 years and over, except when legal obligations must be met.

  • Consent for the Use of Artificial Intelligence (AI) Tools

  • At Wild Child Paediatrics, we may use Artificial Intelligence (AI) tools to assist in administrative tasks and document preparation, such as drafting summaries, reports, or streamlining data entry. These tools are not used for clinical decision-making and are supervised by qualified healthcare providers.

    This form seeks your consent to utilize AI tools during your care while ensuring your personal information is handled securely and in compliance with the Privacy Act 1988 (Cth) and the Australian Privacy Principles.

     
    What AI is Used For:

    1. Assisting with administrative tasks, such as drafting appointment summaries or reports.

    2. Improving the efficiency of document preparation to ensure timely service.

     
    What AI Tools Are NOT Used For:

    • Diagnosing medical conditions.

    • Making treatment decisions.

     All clinical decisions remain the sole responsibility of our qualified healthcare providers.

     

    Data Security and Privacy

    Your data is processed in compliance with Australian privacy regulations. AI tools used in our practice:

    • Handle data securely and in encrypted formats.

    • De-identify personal information wherever possible.

    • Are reviewed and supervised by our healthcare team.

     Your identifiable health data will not be shared with third parties through the use of these tools.

     For further information please see our Privacy Policy.

    Consent

    I/We consent to the use of Artificial Intelligence (AI) tools for administrative and document preparation purposes as part of my child's care at Wild Child Paediatrics.


    I understand that:

    1. AI tools are not used for diagnosing or making clinical decisions.

    2. My child's data will be handled securely and in accordance with Australian privacy laws.

    3. I can withdraw my consent at any time by notifying Wild Child Paediatrics.

     

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