Child Client Admission Form

Referral Information

What are your key concerns?

*To select more than 1 option: Hold "CTRL" or "Command" key.

In your own words, please describe why you are seeking speech pathology for your child. Include examples where relevant.

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About your child

First Name

Date of Birth

*DOB - If you are on desktop browser, click the month and year in black above the calendar to scroll to correct date.

Last Name

Age

Client ID

*Please create a unique client ID for future reference.
Use your child's first name followed by your mobile number with no spaces.
For example: Sarah0400111000

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Doctor

Child's GP

GP's Medical Practice

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Home environment

It helps us diagnose and deliver speech services if we understand you child's living arrangements

Family life. Who is at home. Who is working?

Name of Day care / Pre-School / School

Please provide the name of your child's current teacher if they are at school

What is the primary language spoken at home?

Siblings - Name (Age), Name (Age)

Please provide some general thoughts and feelings about how your child has been doing at school.

Please list some of your child's favourite interests: books/games/hobbies sport?

Please list any other languages your child speaks

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Medical History

Please list all relevant medical history or diagnoses.

How would you describe your pregnancy?

Does your child already have a speech pathology diagnosis?

If yes, do you recall previous therapy goals?

Comment on your child's developmental milestones

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Communication History

We know that its hard to remember this level of detail, but how and when early milestones are reached tell us a lot about how your child's speech and language centres in their brain is developing. If you're unsure, please mark this.

Describe you child's ability to understand language now

Describe your child's ability to use language now

Describe your child's ability to use language

Is there any family history of speech or language difficulties?

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Your Contact Details

First Name

What is your relationship to your child

Mobile Number

Address

Last Name

Home Phone

Suburb

Post Code

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Treating Clinician

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National Disability Insurance Scheme Participants

*Please leave this blank if your child is not an NDIS participant

NDIS Number

SUBMIT

CHILD CLIENT ADMISSION FORM