Happydots Speech Therapy Intake Form

Personal Details

Child’s First name: *

Preferred Name: *

Child's Last name *

Date of birth: *

Gender *

MaleFemaleOther

Do you have any religious requirements that we need to know? If yes, please provide details below.

Do you have any cultural requirements that we need to know? If yes, please provide details.

Preferred Communication:

PhoneEmailPost

Are you in need of physical assistance?

YesNo

Are there any additional considerations? If yes, please provide details.

Caregiver/s Name: *

Relationship to Child: *

Street Address: *

Suburb: *

State: *

Postcode: *

Mobile: *

Email Address *

Do you/the Child speak a language other than English at home?

YesNo

Primary Language

Secondary Language:

Are you in need of an interpreter?

YesNo

Has the child seen a Speech Pathologist before?

YesNo

Please give details:

Do you or your child identify as Aboriginal and/or Torres Strait Islander?

YesNoPrefer not to say

Preferred clinic location

CardiffRaymond TerraceEither

Payment Option Details: NDIS

Are you NDIS Funded? *

YesNo

NDIS Number:

Plan Start Date:

Plan End Date:

How is your NDIS plan managed?

Agency ManagedSelf-ManagedPlan Managed

Happy Dots is registered for Allied Health and Therapeutic supports (0128) we are able to provide early childhood supports if you are plan managed or self managed.

Is your NDIS Plan under ECEI – Early Childhood Supports?

YesNo

Please provide details of you plan management provider if applicable

Name:

Phone:

Email:

Please provide details of the coordinator of supports if applicable

Name of Coordinator of Supports:

Contact Number:

Coordinator of support Email:

Payment Option Details: Third Party

Are you funded for services with a third party? (e.g. Wesley, Department of Communities and Justice, Life without Barriers) *

YesNo

Please provide details if applicable:

Organisation Name:

Contact Person:

Phone:

Email:

Payment Option Details: Private Health

Will you be claiming from your private health fund? *

YesNo

Please provide details if applicable

Organisation:

Member Number:

Payment Option Details: Medicare

Will you be claiming under Medicare? *

YesNo

If yes, please specify below

Chronic Disease Management PlanAutism AustraliaServices for people of Aboriginal or Torres Strait Islander Descent

Happy Dots has a strict 48-hour cancellation and no-show policy. Your appointment time is a contract for the exclusive use of the therapist’s time. A credit card is required at time of booking to secure your appointment. A cancellation fee of $193.99 will be applied to any late cancellations or no show to appointments.

Medical and Developmental History

Does your child have a current diagnosis? If so, please list with dates.

How does your child communicate?

Single words (speech)Non-verbal (body language) PhrasesFull sentences

Comments:

Social History

In order for us to best work with you, we need to know a little about your family. If you are unsure how to answer, feel free to leave those sections for our first session.

Is there a Behavioural Management Plan in Place?

YesNo

Please provide details.

Are there any formal custody arrangements in place?

YesNo

If yes, Please provide details:

If there are any applicable court orders/ Family Law proceedings in place, please provide copy of the orders.

Please provide details of any family history which might impact on the child, i.e., divorce, separation, recent moves or family illness.

For parents of children who are separated or divorced, do both parents know the child will be attended speech pathology services?

Yes No

Education Information

School/Education Setting (include details of Grade level where applicable):

Main Contact Person/Teacher:

Phone:

Email:

Reason for Referral

So we can prepare the most appropriate service to your needs, we would like more information about what has brought you to Speech Pathology services. We also like to reach out to common referrers to offer additional supports.

What are the main concerns regarding the child’s communication? Include when the problem was noticed, who noticed it and where the problem occurs.

What do you want to achieve for your child by coming to Speech Pathology services?

How did you find out about us?

Is there anything else you feel we should know to assist supporting you and your child?

Areas of Concern

Additional Comments:

Please provide any previous reports from other service providers that you think would be helpful.

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