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How did you hear about us:(Required)

Clinic Preference:(Required)

Select Day(Required)

Session Time(Required)

NDIS Funding:(Required)

Self Managed

Plan Managed

Agency Managed

No Funding

Child’s Information:

Child's Full Name:(Required)

Date of Birth:(Required)

MM slash DD slash YYYY

Has your child received any formal diagnosis of any kind?(Required)

Yes

Diagnosis received:(Required)

Age of diagnosis:(Required)

Allergies:(Required)

Special Diet(s):(Required)

Current School:

Grade/Class:

Additional Support at school?

Yes

OTHER SERVICES

Speech Services:

Yes

Occupational Therapy:

Yes

Other:

Parent’s / Guardian’s Information:

Mother’s Full Name:(Required)

Mother’s Phone number:(Required)

Mother’s Email:(Required)

Father’s Full Name:(Required)

Father’s Phone number:(Required)

Father’s Email:(Required)

Address:(Required)

Communication and Behaviour:

What is your child’s main method of communication (i.e., sign language, gestures, pictures, verbalizations – if so, how many word phrases)? Briefly describe how he/she gets his/her needs met.

Does your child have any negative behaviours that you are concerned about (aggression, tantrums, non-compliance)? Please describe.

Reinforcement:

List some of your child’s likes:

List some of your child’s dislikes:

Goals:

Fill in only the applicable categories. Be as specific as possible.

Language/Communication Goals:

Behaviour Reduction Goals:

Academic Goals:

Self-Help Goals:

Play/Leisure Skills Goals:

Social Skills Goals:

Gross Motor Goals:

Fine Motor Goals:

Other:Use this section to write in any additional information that you want us to know

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Enquiry Form