Brownyn Sutton Speech Pathology Intake Form

CHILD'S DETAILS

Full Name *

Date of Birth *

Home Address

Street address

City

State

Postcode

Child Care/School

School Address

Street address

City

State

Postcode

PARENT'S/CARER'S DETAILS

Parent/Carer 1 Name

Mobile

Occupation

Parent/Carer 2 Name

Mobile

Occupation

YOUR CHILD'S THERAPY TEAM

OT Name

OT Email

Psychologist Name

Psychologist Email

Paediatrician Name

Practice

Other professional/s

ABOUT MY CHILD

My child's diagnosis

What does your child enjoy and do well?

What concerns you, and what don’t you understand about your child?

YOUR CHILD'S DEVELOPMENT

Any concerns about your child’s health currently?

YesNo

Comments

Any concerns about the pregnancy and birth?

YesNo

Comments

Any concerns about your child’s milestones?

YesNo

Comments

Has your child had a hearing test from an audiologist?

YesNo

Comments

YOUR FAMILY

Does anyone in your family have similar problems to your child?

YesNo

Comments

Does anyone in your family have different learning or developmental problems?

YesNo

Comments

AUTISM SPEECH THERAPY PARENT COACHING

Please read the “About Bronwyn Sutton Speech Pathology” document.

I understand that a parent/carer should attend every session

YesNo

Comments

I understand parents are actively involved in each session while being coached by Dr Sutton

YesNo

Comments

SERVICE AGREEMENT

Are there any professionals you DO NOT want us to contact?

YesNo

Comments

Do you permit Dr Sutton to email reports and plans to you?

YesNo

Comments

I understand that appointments will change to telehealth if Dr Sutton needs to isolate.

YesNo

Comments

I understand and accept the CDN Practice Policies. *

Child Minding Policy

The CDN administrative staff are not in a position to provide child care or supervise your child.

If you anticipate that your child might be required to spend time in the waiting room without you, and would require supervision during that time, then please arrange for a suitable adult to attend your consultation with you, so that they can be with your child as they wait.

If you are unsure if this applies to your circumstances then please ask your Clinician or the administration staff prior to your visit.

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Date

Thank you for taking the time to complete this questionnaire.