BOOKING FORM: CHILD PART B

Child's Name

Child's Date of Birth

Parent/Guardian's Name

Child's Age

Email Address

Phone

Siblings’ Names and Ages

Emergency Contact Details

Emergency Contact Relationship to Client

Emergency Contact Number

Medical Practitioner | Referring Doctor if Applicable (not necessary)

Medical Practitioner | Referring Doctor

Medical Practitioner | Referring Doctor

Medical and Developmental History And Reports Please provide copies of relevant medical reports File InputChoose FilesNo Files ChosenAccepted file types: jpg, jpeg, jpe, gif, pdf, doc, docx. Max. file size: 10 MB

Are there any diagnosed illnesses/disorders? Are there any diagnosed illnesses/disorders? Yes No

Please specify

Were there any difficulties during pregnancy or birth? Were there any difficulties during pregnancy or birth? Yes No

Please specify

Was your child late to achieve speech/language/play/friendship milestones? Was your child late to achieve speech/language/play/friendship milestones? Yes No

Please specify

Were there any feeding difficulties during infancy? Were there any feeding difficulties during infancy? Yes No

Please specify

Is there is a history in your family of speech, language, feeding, social communication or other difficulties related to your concern? Is there is a history in your family of speech, language, feeding, social communication or other difficulties related to your concern? Yes No

Please specify

Has your child’s hearing been tested? Has your child’s hearing been tested? Yes No

Please attach reports File InputChoose FilesNo Files ChosenAccepted file types: jpg, jpeg, jpe, gif, pdf, doc, docx. Max. file size: 10 MB

Is there a history of middle ear infections/known or suspected hearing loss? Is there a history of middle ear infections/known or suspected hearing loss? Yes No

Please attach reports File InputChoose FilesNo Files ChosenAccepted file types: jpg, jpeg, jpe, gif, pdf, doc, docx. Max. file size: 10 MB

Current Year Group

Current School

Current Teacher

Educational Reports Please provide copies of relevant educational reports File InputChoose FilesNo Files ChosenAccepted file types: jpg, jpeg, jpe, gif, pdf, doc, docx. Max. file size: 10 MB

Does your child experience any difficulty relating to other children or adults? Does your child experience any difficulty relating to other children or adults? Yes No

Please specify

Has your child been assessed by a Speech Pathologist or received speech therapy? Has your child been assessed by a Speech Pathologist or received speech therapy? Yes No

Please specify

Speech Therapy Reports Please provide copies of relevant speech therapy reports File InputChoose FilesNo Files ChosenAccepted file types: jpg, jpeg, jpe, gif, pdf, doc, docx. Max. file size: 10 MB

Has your child been assessed by another allied health professional (Psychologist, Physiotherapist, Occupational Therapist)? Has your child been assessed by another allied health professional (Psychologist, Physiotherapist, Occupational Therapist)? Yes No

Please specify

Allied Health Reports Please provide copies of relevant therapy reports File InputChoose FilesNo Files ChosenAccepted file types: jpg, jpeg, jpe, gif, pdf, doc, docx. Max. file size: 10 MB

How many different foods can your child currently eat? How many different foods can your child currently eat? 0-5 6-12 13-20 More than 20

My child eats a range of foods My child eats a range of foods Never Rarely Sometimes Often Always

My child is happy, regulated and will stay at the table for the duration of their meal My child is happy, regulated and will stay at the table for the duration of their meal Never Rarely Sometimes Often Always

My child appears to enjoy eating My child appears to enjoy eating Never Rarely Sometimes Often Always

I feel worried or concerned about my child’s eating/mealtimes I feel worried or concerned about my child’s eating/mealtimes Never Rarely Sometimes Often Always

Level of impact on our daily life is Level of impact on our daily life is No Impact Low Impact Moderate High Impact Very High Impact

My child transitions between activities smoothly My child transitions between activities smoothly Never Rarely Sometimes Often Always

My child easily tolerates a range of sensory experiences (e.g. loud noises, crowded places, clothing) My child easily tolerates a range of sensory experiences (e.g. loud noises, crowded places, clothing) Never Rarely Sometimes Often Always

Level of impact on our daily life is Level of impact on our daily life is No Impact Low Impact Moderate High Impact Very High Impact

My child can easily understand instructions/questions My child can easily understand instructions/questions Never Rarely Sometimes Often Always

My child uses spoken language to get needs met My child uses spoken language to get needs met Never Rarely Sometimes Often Always

My child uses spoken language to get information from others My child uses spoken language to get information from others Never Rarely Sometimes Often Always

Level of impact on our daily life is Level of impact on our daily life is No Impact Low Impact Moderate High Impact Very High Impact

My child is easy to understand My child is easy to understand Never Rarely Sometimes Often Always

Level of impact on our daily life is Level of impact on our daily life is No Impact Low Impact Moderate High Impact Very High Impact

My child can tell stories about their experiences My child can tell stories about their experiences Never Rarely Sometimes Often Always

My child can have a go at most tasks at school with minimal distress My child can have a go at most tasks at school with minimal distress Never Rarely Sometimes Often Always

Reading is a strength for my child Reading is a strength for my child Never Rarely Sometimes Often Always

Level of impact on our daily life is Level of impact on our daily life is No Impact Low Impact Moderate High Impact Very High Impact

My child can hold pencil and scissors well enough to complete tasks My child can hold pencil and scissors well enough to complete tasks Never Rarely Sometimes Often Always

Level of impact on our daily life is Level of impact on our daily life is No Impact Low Impact Moderate High Impact Very High Impact

My child stays awake late into the night My child stays awake late into the night Never Rarely Sometimes Often Always

My child wakes frequently or early My child wakes frequently or early Never Rarely Sometimes Often Always

Level of impact on our daily life is Level of impact on our daily life is No Impact Low Impact Moderate High Impact Very High Impact

My child is independent or motivated with dressing/toileting/hygiene My child is independent or motivated with dressing/toileting/hygiene Never Rarely Sometimes Often Always

My child is happy to complete care routines (e.g. hair brushing) with prompting My child is happy to complete care routines (e.g. hair brushing) with prompting Never Rarely Sometimes Often Always

My child easily engages with morning/bedtime routine My child easily engages with morning/bedtime routine Never Rarely Sometimes Often Always

Level of impact on our daily life is Level of impact on our daily life is No Impact Low Impact Moderate High Impact Very High Impact

Following my child’s lead during play or activities Following my child’s lead during play or activities Not at all confident A little Somewhat confident Confident Very confident

Using simple, clear language my child can understand Using simple, clear language my child can understand Not at all confident A little Somewhat confident Confident Very confident

Giving my child enough time to respond or talk Giving my child enough time to respond or talk Not at all confident A little Somewhat confident Confident Very confident

Using gestures, facial expressions, and tone to support communication Using gestures, facial expressions, and tone to support communication Not at all confident A little Somewhat confident Confident Very confident

Commenting on what my child is doing or saying rather than using questions to test Commenting on what my child is doing or saying rather than using questions to test Not at all confident A little Somewhat confident Confident Very confident

Reading books with my child to encourage engagement and interaction Reading books with my child to encourage engagement and interaction Not at all confident A little Somewhat confident Confident Very confident

Using age-appropriate, clear language my child can understand Using age-appropriate, clear language my child can understand Not at all confident A little Somewhat confident Confident Very confident

Using interaction styles that support positive communication Using interaction styles that support positive communication Not at all confident A little Somewhat confident Confident Very confident

Giving my child enough time to express ideas and thoughts Giving my child enough time to express ideas and thoughts Not at all confident A little Somewhat confident Confident Very confident

Asking open-ended questions to encourage detailed responses (e.g., “What do you think?” or “How did that make you feel?”) Asking open-ended questions to encourage detailed responses (e.g., “What do you think?” or “How did that make you feel?”) Not at all confident A little Somewhat confident Confident Very confident

Commenting on and expanding what my child says to model more complex sentences Commenting on and expanding what my child says to model more complex sentences Not at all confident A little Somewhat confident Confident Very confident

Encouraging my child to explain ideas, feelings, and opinions Encouraging my child to explain ideas, feelings, and opinions Not at all confident A little Somewhat confident Confident Very confident

Using everyday routines or shared activities to practice new vocabulary or problem-solving Using everyday routines or shared activities to practice new vocabulary or problem-solving Not at all confident A little Somewhat confident Confident Very confident

Reading and discussing story content, characters, and themes together Reading and discussing story content, characters, and themes together Not at all confident A little Somewhat confident Confident Very confident

Encouraging reflection on daily experiences and feelings Encouraging reflection on daily experiences and feelings Not at all confident A little Somewhat confident Confident Very confident

I understand that if I have any questions or concerns regarding my child’s treatment, I should discuss them with the Speech Pathologist before signing this consent. I understand that if I have any questions or concerns regarding my child’s treatment, I should discuss them with the Speech Pathologist before signing this consent. Yes No

I understand that at times, it is important for my child’s clinical information to be shared with other relevant Professionals, such as a GP, a referring Specialist, Teacher/Educator or an Allied Health Professional. I understand that at times, it is important for my child’s clinical information to be shared with other relevant Professionals, such as a GP, a referring Specialist, Teacher/Educator or an Allied Health Professional. Yes No

I understand that a minimum of 24 hours notice is required for appointment changes or cancellations and that those appointments cancelled or changed with less than 24 hours notice may incur a $115.00 fee. I understand that a minimum of 24 hours notice is required for appointment changes or cancellations and that those appointments cancelled or changed with less than 24 hours notice may incur a $115.00 fee. Yes No

I consent to my child's treatment by Speechcare. I consent to my child's treatment by Speechcare. Yes No

I consent to the release of my child’s clinical information to relevant professionals if needed, with the understanding that I will be consulted before any information is shared. I consent to the release of my child’s clinical information to relevant professionals if needed, with the understanding that I will be consulted before any information is shared. Yes No

The information I have provided is correct and complete. The information I have provided is correct and complete. Yes No

Signed SaveClear

Date