Client Information Form -Please allow approximately 15 minutes to complete this form- Client Information - Child Step 1 of 9 11% Child and Family InformationChild's name:* First Last Date of Birth* DD slash MM slash YYYY Members of Family / HouseholdPrimary parent / guardian name:* First Last Secondary parent / guardian name: First Last Language/s spoken at home: Interpreter neededNoYesDo you identify as as being of Aboriginal or Torres Strait Islander descentNoYesWho lives at home (please include the age of any siblings)?If parents are living separately, who will be available for the appointment? About Your Child:How would you describe your child?What are the main concerns you have about your child and his/her development? When did you first become concerned? How did you come to be referred to us? What have you already tried to help your child? Family History:Has anyone in your family had speech/language/learning difficulties or dyslexia? Yes No Tell us more:Has anyone in your family had speech therapy? Yes No Tell us more:Medical History:1. How was your health during your pregnancy with this child?2. Was your child born: Full Term Early Late How early?* 3. Were there any complications or problems with you or your baby during or after birth?Your Child's Health:1. Has your child been admitted to hospital (i.e. overnight)? Yes No 2. How would you describe your child’s health: Poor Fair Good 3. Has your child had any ear infections? Yes No 4. Has your child had a hearing assessment? Please give date/ dates and result. 5. Has your child had a vision assessment? Please give date/ dates and result. 6. Please list any medications that your child is taking at this time.7. Has your child been diagnosed with another condition? e.g. Intellectual Disability, Down Syndrome, Epilepsy, Attention Deficit Disorder or Attention Deficit Hyperactivity Disorder. Your Child's History When did your child first do the following: (If you can recall, record age at which your child reached the following development milestones; if you cannot recall exactly, indicate early, late or normal. It may be helpful to talk with others in your family or look at photographs of your child).FeedingAs an infant, were there any difficulties with :Breast / bottle feeding?NoYesDiet?NoYesIntroducing solids?NoYesWeight gain?NoYesAre there any current concerns with diet /feeding?NoYesPlease Explain:Sleeping:Has there ever been any difficulties with sleeping?As an infant?NoYesPlease Explain:Currently?NoYesPlease Explain: Your Child's History (Continued) When did your child first do the following: (If you can recall, record age at which your child reached the following development milestones; if you cannot recall exactly, indicate early, late or normal. It may be helpful to talk with others in your family or look at photographs of your child).Motor:Rolled over: Sat Without Help: Crawled: Walked Alone: Is your child clumsy? Are there difficulties with gross motor skills such as running?NoYesPlease Explain: Have you ever had any concerns about slow development in any area?NoYesPlease Explain: Your Child's History (Continued) When did your child first do the following: (If you can recall, record age at which your child reached the following development milestones; if you cannot recall exactly, indicate early, late or normal. It may be helpful to talk with others in your family or look at photographs of your child).LanguageSmiled: Babbled: Was Babble Interactive?NoYesFirst words (Other than mum / dad): What were some of the early words? Put Two Words Together? Useful Sentences? Spoke Clearly? Toilet Training:Is your child toilet-trained night and day? What else does your child do?Please list Playgroups, Child Care, or other groups which your child has attended and the dates:Playgroup Please include location, start date, when they attend and is support required Child Care Please include location, start date, when they attend and is support required ECIS Please include location, start date, when they attend and is support required Pre-School Program Please include location, start date, when they attend and is support required Please list add any other services your child attends Please include location, start date, when they attend and is support required Other People who have Seen Your ChildPlease list any other people who have been involved in your child's care (e.g. Paediatrician, Speech Pathologist, Occupational Therapist, Neurologist, Psychologist / School Psychologist, ENT Specialist, Social Worker, Audiologist). Other people who have seen my child: Please add as many lines as required and include, name, date and reason for each visit.AvailabilityPlease mark the days/times when you are available to attend a therapy appointment for your child. Select All Monday AM Monday PM Tuesday AM Tuesday PM Wednesday AM Wednesday PM Thursday AM Thursday PM Friday AM Friday PM Receive a copy of this formYour Email
