Please complete the details: Child’s DetailsFirst Name*Middle NameLast Name*Preferred NameDate of Birth (dd/mm/yyyy)*Age*Gender*MaleFemaleOtherPrefer not to sayNationality:Languages other than English Spoken at Home:Do you identify as Aboriginal or Torres Strait Islander? Yes No Parent/Carer DetailsParent/Carer Name 1*Relationship to child*Address*Suburb*Email* Phone (Mobile)*Add Details for another parent/carer?* Yes No Parent/Carer Name 2Relationship to childAddressSuburbEmail Phone (Mobile)Alternative living/custody arrangements:FundingFunding:*Private PayingGP Referral/Care PlanNDISOtherDetails if Other:NDIS Number:Plan Date Start: DD slash MM slash YYYY Plan Date Finish: DD slash MM slash YYYY How is your NDIS managed ? Self Managed Plan Managed Funding other than NDIS EducationSchool/Kindy/Daycare:Grade:Teacher/Support Name:Contact details:Additional Supports in the learning environmentMedical HistoryDiagnosis/pre-existing condition:*Medication:*Allergies/Intolerances (please indicate if anaphylactic):*Does your child communicate verbally?* Yes No Describe their current methods of communication* AAC Device Gesture Single Words Short sentences Engages in conversation Other Previous Therapy/Medical Intervention:*Health Care Team/Other Therapists Involved:Paediatrician* Yes No Paediatrician DetailsHas your child had a recent hearing test?* Yes No Date of last test:*Test Results:Developmental HistoryAge Crawled?Age Walked:Age First WordsAge Ate SolidsAny Concerns?About your childWhat are your child’s strengths?What does your child have difficulties with (home and school)?What are your child’s interests?What does your child dislike?Able to transition between tasks/spaces?Please complete the required therapy sections belowEarly Intervention EducatorDoes your Child require Early Intervention Education Support?** Yes No At Able Kids Therapy we have an Early Interventions Educator who can support children with their development up to the age 9 years of age. Would you be interested in utilising this service to assist in any of the following areas, please tick all that apply. Language Behaviour Social Skills Academic Skill Emotional Regulation Prep Readiness Fine Motor Skills Gross Motor Skills Parental Support Speech PathologyDoes your Child require Speech Pathology Support?* Yes No Is there a family history of speech/language concerns?Does your child have any difficulties with any speech sound?How well is your child understood by family members? Less than 50% More than 50% How well is your child understood by strangers? Less than 50% More than 50% Does your child display difficulties in the following language areas: Remembering spoken information Following directions Requesting for needs and wants Understanding the meaning of words Answering questions Telling stories that make sense Using words accurately in context Putting words together in a sentence Continuous repletion of words/phrases they hear Grammar Additional Comments:Does your child display any difficulties in the following social skill areas? Playing with others Imaginative play Structured play e.g. playing games with rules Staying on topic in conversation Initiating conversations Turn taking Using appropriate means to gain attention Sharing too much or too little information Understanding figurative language e.g. sarcasm/idioms/metaphors Understanding non-verbal communication e.g. tone of voice, facial expressions Using appropriate body language Additional Comments:Does your child display any difficulties in the following literacy skill areas? Recognising letter names Recognising letter sounds Sounding out words Spelling Reading Reading comprehension Additional Comments:Does your child display any stuttering behaviours? Repeating sounds Repeating parts of words Repeating whole words Getting Stuck Stretching out sounds When did you first notice/become concerned?Is there a family history of: Persistent stuttering Resolved stuttering None Has day-care/kindy/prep preschool raised similar concerns? Yes No Additional Comments:Occupational TherapyDoes your child require Occupational Therapy Support?* Yes No Gross Motor Yes No Please tick any areas of concern regarding your child’s gross motor skills Running Skipping Jumping Hopping Throwing Catching Balancing Endurance Fine Motor Yes No Please Tick any areas of concern regarding your child’s fine motor skills Holding pencils/crayons Forming letters/numbers Snipping with scissors Drawing simple pictures Doing up buttons/zips Making Lego Jewellery or threading Other Has your child established a dominant hand? Yes, Right Yes, Left Both None Self-Care (including dressing, toileting, grooming, showering etc.) Yes No Dressing (including buttons, shoelaces, etc) Independent Needs some help Needs a lot of help Dressing additional concernsToileting Independent Needs some help Needs a lot of help Toileting - Additional comments:Grooming (including brushing teeth/hair, etc) Independent Needs some help Needs a lot of help Grooming - Additional comments:Showering / Bathing Independent Needs some help Needs a lot of help Showering / Bathing - Additional comments:Inattention/Energy/Impulsivity Yes No Behaviour Yes No Social Skills Yes No Please tick any areas of concern regarding your child’s social skills Making/keeping friends Eye contact Personal space Appropriate topic of conversation Managing emotions Tantrums/meltdowns Other Sensory Processing Yes No Please tick any areas of concern regarding your child’s sensory processing skills Sensitivity to bright lights Sensitivity to loud noises Difficulty with certain textures eg: food, clothing etc Needing to fidget more than peers (ie: touching/fiddling with objects) Other Feeding/SwallowingDoes your child display any difficulties regarding feeding/swallowing?* Yes No Please tick all that apply Eating limited amounts of food Eating limited variety of foods Eating limited variety of food textures Coughing/choking/spluttering when eating or drinking Refusing entire food groups e.g. meats, fruits, vegetables Often eats a different meal from the rest of the family Mealtimes cause stress/anxiety for the family Long mealtimes Chewing difficulties Strong gag reflex Avoiding cutlery When was their last dentist visit?Have they had a recent blood test? Yes No Do they experience constipation? Yes No Please indicate your top priorities for therapy:Group TherapyAt Able Kids Therapy we offer a variety of groups to support our clients.Please tick all groups that you are interested in attending: Prep Readiness Social Skills Sounds-Write Literacy Messy and Sensory Play Music Therapy Lego None of the above
