PARTICIPANT INFORMATION

Participant Details

First Name *

Last Name *

Participant's Date of Birth *

Country of Birth

Participant's Gender

Family Details

Address *

Suburb *

State *

Post Code *

Home Phone

Mobile Phone *

Email Address *

Biological Parents *

YesNo

Carer *

YesNo

Parent / Guardian 1

Parent / Guardian 2

Parent / Guardian Name

Parent / Guardian Age

Parent / Guardian Occupation

Relationship Status

Court Orders (previous or current) - Please provide details.

Children in the family

Name *

Date of Birth

Who lives at home? ( list names and relationship) *

What languages are spoken at home? *

Are there other important people in the Participants life? Please explain

What is the Participants preferred language? *

Does the Participant or family identify as being Aboriginal or Torres Straight Islander Decent? *

What is the Participant's native background? *

Does the Participant have any cultural considerations? *

Do you or Participant require an interpreter? *

YesNo

Has the Participant experienced any significant life events? *

YesNo

Please explain

Do you have support people / services in place? *

YesNo

Please explain

Family History

Has anyone else in the family (children or adults) ever had

Speech and/or language difficulties? *

YesNo

Please provide details

Education/learning difficulties? *

YesNo

Please provide details

Physical problems/difficulties? *

YesNo

Please provide details

Developmental disability? *

YesNo

Please provide details

Emotional problems? *

YesNo

Please provide details

Attention problems? *

YesNo

Please provide details

History of Pregnancy and Birth

What was the Participant's APGAR score at birth?

During the Participants pregnancy and birth did the mother and/or baby have any difficulties? - please describe *

Participant born at (how many weeks ) i.e 40 Weeks *

Participant birth weight (kilograms) *

Did participant require any special treatment after birth? *

Developmental Milestones

Speech and Language Development

Please select yes and then (weeks, months,years) followed by number to provide the participants age of acquisition. Select N/A if not acquired.

Babble *

YesN/A

Age

No.

Speak single words (e.g. drink, car) *

YesN/A

Age

No.

Speak in 2 more or words together (e.g. more drink, dad work) *

YesN/A

Age

No.

Speak in longer sentences *

YesN/A

Age

No.

Read *

YesN/A

Age

No.

Count *

YesN/A

Age

No.

Repeat alphabet *

YesN/A

Age

No.

Motor/Self Help

Sit *

YesN/A

Age

No.

Roll *

YesN/A

Age

No.

Crawl *

YesN/A

Age

No.

Walk *

YesN/A

Age

No.

Independent toileting (day) *

YesN/A

Age

No.

Independent toileting (night) *

YesN/A

Age

No.

Dress themselves *

YesN/A

Age

No.

Bathe themselves *

YesN/A

Age

No.

Sleep in their bed *

YesN/A

Age

No.

Brush their own teeth *

YesN/A

Age

No.

Did/does your the Participant fall or lose balance easily? *

YesNo

Please describe.

Did/does the Participant seem awkward or clumsy? *

YesNo

Please describe.

Did/does the Participant have any unusual habits/behaviours ? - please describe. *

Eating, Drinking and Tool Use

Did the Participant have feeding problems as a baby? - please describe. *

Does/did the Participant have any eating/drinking problems? - Please describe. *

Is the Participant a fussy eater? - What foods does the Participant eat? please list. *

At approximately what age did the participant?

Start to use utensils (weeks, months, years) *(e.g. spoon, fork)

Start to use bottle/sipper cup (weeks, months, years) *

Start to use cup (weeks, months, years) *

Medical History

List any illnesses, hospital stays or significant experiences the Participant has had, and at what age they occurred *

Does the Participant have a diagnosis? *

YesNo

Please list diagnosis and by who/when

Has the Participant's vision been checked? *

YesNo

When? What were this result.

Has the Participant's hearing been checked? *

YesNo

When? What were this result.

Has the Participant had grommets inserted? *

YesNo

When? What were this result.

How often does the Participant have a cold and/or the flu? *

OftenSometimesNever

Has the Participant had any ear infections? *

YesNo

How many per year?(Approximately)

When was the last episode?

Treatment

Has the Participant ever had any convulsions or fits? *

YesNo

When was the last episode?

Is the Participant on any medication at present? *

YesNo

Please give details of the medication and purpose

Does the Participant have any allergies? *

YesNo

What are they allergic to?

Other Professionals

Has the Participant been seen by or on a waiting list to see any of the following professionals?

Paediatrician *

YesNo

Name of Pediatrician / Last Visit / Upcoming appointments

Special Needs Teacher *

YesNo

When

Ear, Nose and Throat Specialist *

YesNo

When

Social Worker *

YesNo

When

School Counsellor *

YesNo

When

Occupational Therapist *

YesNo

When

Psychologist *

YesNo

When

Speech Pathologist *

YesNo

When

Physiotherapist *

YesNo

When

Music Therapy *

YesNo

When

Dietician *

YesNo

When

Art Therapist *

YesNo

When

Any other specialist or clinic

YesNo

When

Please list any other medical or allied health providers the participant is currently seeing along with their contact details.

Additional Information

Does the Participant snore? *

YesNo

Does the Participant suck his/her thumb or dummy? *

YesNo

Please specify

ThumbDummy

Preschool / School

Name of current preschool/school *

Address

Phone number

Day’s attending *

Teacher *

Grade *

How well does the Participant interact with others? *

PoorReasonableVery Well

Comment -the Participant's Interaction with others.

Has the Participant repeated any classes or changed schools? *

YesNo

Please provide details.

Does the Participant have a support teacher/reading recovery? *

YesNo

What is the Participant's average performance at school? *

PoorAverageConsistently Good

Comment

Parent/Guardian Concerns

Please describe your concerns about the Participant *

How does your child get on with?

Participant's Profile

What does the Participant enjoy doing? *

Please describe the Participant’s motivator’s/interests? *

Are there things that the Participant dislikes? *

Family Goals for Intervention

What would you like to achieve through accessing support services with Inspire Allied Health and Education Group. *

Other

Please provide any additional information which you feel will help us to understand the Participant better

NDIS Funding

Do you have NDIS Funding? *

YesNo

Are you ? *

Self ManagedPlan ManagedNDIA Managed

Plan Manager - please provide plan manager details

NDIA Managed - please provide NDIS number

The time and effort you have put into completing this form is greatly appreciated and will assist in providing holistic support service of the participant.

Name of person filling in this form *

Date

Clinic location

Signature *

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