Intake Form

Child details

Child's Name

Date of Birth

Child's pronouns

Child's sex

Parent / Guardian Name

Parent / Guardian's pronouns

Contact Phone Number

Email Address

Home Address

Emergency Contact for Child

Name

Emergency contact's pronouns

Relation to child

Contact Phone Number

General details

NDIS Plan Manager Contact Details (If applicable)

Holidays

1. Do you agree to our services of trade and policies outlined in handbook?

Yes

2. How would you like to be contacted with information relating to your appointments and our services?

3. Are there any family arrangements or court orders in place to protect members of your family? If yes, please provide us with documentation to keep on file.

Yes

Other

4. Who are the primary people in your child’s life?

5. Overview of child’s history (birth complications/family dynamics or exposure to harmful situations/history of DV, alcohol or drug use?):

6. Does your child have any formal diagnosis or delays? (This includes medication your child may be taking, medical conditions or allergies etc)

7. Results of your child’s developmental assessments (only applicable for Child Development Sessions)

8. What are some of the activities you enjoy with your child and doing together as a family?

9. What are your child’s strengths?

10. What are your child’s primary interests?

11. What are some of the main concerns you have for your child?

12. Is this child currently engaging with any other services? If so, please indicate below:

13. What goals would you me to add to your child’s therapeutic plan/educational support plan?

14. What are the primary goals school/NDIS would like to be included in your child’s educational plan?

15. How regular would you like me to schedule our parent support/feedback sessions?

Every 4 weeks

Every 6 weeks

Every 8 weeks

Every 12 weeks

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Intake Form

Child details

Emergency Contact for Child

General details

Referral Form