Kylie Hinde Intake Form

Psychology Intake Questionnaire

This questionnaire is designed to help us understand your child’s unique strengths, needs, and experiences, and to guide how we support them and your family. We recognise that every child is different. There are no right or wrong answers, and you are welcome to share as much or as little detail as feels comfortable.

Welcome & Family Information

Thank you for taking the time to complete this form. The information you provide helps us build a meaningful understanding of your child and how best to support them.

Child's Details

Child's Full Name *

Preferred name (if different)

Date of Birth *

Age

Gender

Pronouns

Person Completing This Form

Name *

Relationship to child

Date completed *

Family & Household

Please tell us about the people your child loves with or spends significant time with:

Name

Relationship to child

Age

Care Arrangements

Are there any current care or custody arrangements we should be aware of?

If your child is in a shared care arrangement, please provide the name and contact details of the other parent or caregiver:

*Where care is shared, consent from all legal guardians may be required before therapy can begin.

Legal Considerations

Are there any current or upcoming legal proceedings we should be aware of?

YesNo

If yes, please provide details

Important Information About Use of Services

Dr Kylie Hinde’s services are focused on therapeutic support and are not intended for use in legal proceedings (e.g., court matters, insurance or NDIS disputes, or investigations).

If you are currently involved in, or anticipate becoming involved in, legal processes, please let us know. In some cases, referral to a clinician who specialises in medico-legal work may be more appropriate to ensure your child and family receive the right type of support.

Presenting Concerns & Goals

What has led you to seek psychological support at this time?

What are your main hopes or goals for your child through therapy?

What would you most like your child to feel, experience, or be able to do differently?

Please describe your child’s current strengths

What tasks or activities feel more effortless or sustaining to your child?

What tasks or activities feel more effortful or difficult for your child?

Is your child currently working, studying, or doing something else? Tell me a bit about what fills your child’s days

Does your child have any strong or passionate interests? (Please share as much or as little as you would like)

Early Development & Birth History

Every child develops in their own way and at their own pace. The following questions help us understand your child’s early experiences and development.

Pregnancy & Birth

Were there any experiences during pregnancy that you feel are important for us to know? (e.g., health, stress, medical factors)

Was the birth parent taking any medications during pregnancy?

NoYes (please describe)

Birth Details

Gestation

Full termPrematureLate

If premature/late, how many weeks?

Birth weight

Were there any complications during labour or delivery?

NoYes (please describe)

Did your child experience any medical or developmental needs shortly after birth? (e.g., NICU stay, feeding, breathing, settling)

NoYes (please describe)

Early Development

Children reach developmental skills at different times. The information below helps us understand your child’s early developmental pattern. Approximate ages are completely okay.

Responded to familiar people (e.g., smiling, eye contact, engagement)

Sat independently

Babbled

Rolled over

Crawled or moved independently

Spoke first words

Early Development Reflections

Looking back, how would you describe your child as a baby or toddler? (e.g., temperament, sleep, feeding, sensory preferences, connection with caregivers)

Were there any early differences, strengths, or challenges that stood out to you?

Social and Emotional Development

Every child has their own way of communicating, connecting, and responding to the world. The following items help us understand your child’s unique profile, including both strengths and areas where they may need support. (Please tick any that you currently observe)

Communication & Connection

Communicates in ways that can be hard for others to understand at timesPrefers solitary play or time aloneFinds social interaction tiring or overwhelmingExperiences challenges navigating peer relationshipsExperiences challenges in sibling relationships

Emotional Experience & Regulation

Experiences big emotions or becomes easily overwhelmedHas strong emotional reactions (e.g., distress, frustration)Avoids situations that feel anxiety-provoking or overwhelmingHas specific fears or worriesAppears more cautious, shy, or slow to warm upMay express distress in ways that impact others (e.g., hitting, yelling)

Interests & Attention

Has strong or highly focused interestsPrefers objects, systems, or specific topics of interestSpends significant time engaged in preferred interests (e.g., gaming, technology)

Behaviour & Safety

Finds it hard to follow expectations or boundaries at timesEngages in behaviours that may be unsafe or riskyMay be described as “often in trouble” in some settings

Sleep, Eating & Daily Needs

Experiences difficulties with sleep (e.g., falling asleep, staying asleep, nightmares)Has a limited range of foods or challenges with eatingExperiences toileting challenges (e.g., accidents, bedwetting)

Education & Learning

We understand that children engage with learning environments in different ways. The following questions help us understand your child’s educational experiences, supports, and needs.

Educational History

Please list the educational settings your child has attended:

Day care/Early learning

Kindergarten/Prep

Primary school

High school

Learning Experience

How does your child generally experience school or their learning environment? (e.g., enjoyment, engagement, friendships, challenges)

Areas of Support

Are there any areas where your child has needed additional support at school? (e.g., learning, attention, emotional wellbeing, social connection, transitions)

School supports

Has your child received any additional supports or adjustments at school? (e.g., learning support, aide, individual education plan, accommodations)

NoYes (please describe)

Learning Profile

Based on recent school reports or feedback, how is your child progressing?

Mostly meeting expectationsAbove expectations in some areasRequires additional support in some areas

If support is needed, which areas are most relevant?

Health & Medical History

The following information helps us understand your child’s overall health and any factors that may influence their wellbeing.

Current Health

Does your child have any current medical conditions or health needs?

NoYes (please describe)

Medications

Is your child currently taking any medications?

NoYes (please list medications and reasons - if known)

Past Health

Has your child experienced any significant illnesses, injuries, or hospitalisations?

NoYes (please describe)

Family Context

Is there any family history of developmental, learning, or mental health differences we should be aware of? (This can help us better understand your child’s profile and support needs.)

NoYes (please describe)

Sensory and Communication Preferences

Does your child have any sensory sensitivities or preferences we should know about? (e.g., lighting, sounds, environment)

Does your child have any preferences around communication? (e.g., direct/indirect, visual/verbal/written, pace, checking in)

Support & Therapy History

Understanding your child’s previous supports helps us tailor our approach in a way that feels safe, helpful, and aligned with their needs.

Previous Therapy or Support

Has your child previously worked with a psychologist or other professional for emotional, behavioural, or developmental support?

NoYes (please provide details)

What has felt helpful

What aspects of past support have been helpful for your child or your family? (e.g., approach, communication style, pacing, types of activities, therapist qualities)

What has felt less helpful

Were there any aspects of past support that did not feel helpful or did not suit your child?

Current or past allied health supports

Is your child currently, or have they previously been, supported by other professionals? (e.g., speech pathology, occupational therapy, paediatrics, psychiatry)

NoYes (please provide details including therapist names and focus of support)

If available, you are welcome to share any relevant reports (e.g., assessments, diagnostic reports, school reports) to help us build a clearer understanding of your child.

Parent/caregiver perspective

Is there anything you have found particularly helpful when supporting your child at home?

Supporting Your Child’s Needs and Behaviour

We understand that all behaviour is communication. The following questions help Dr Kylie Hinde to understand how you currently support your child when they are having a hard time, and what feels helpful for your family.

Is there anything you have found particularly helpful or unhelpful when supporting your child?

Technology & Digital Interests

We recognise that technology can play many roles for children, including connection, regulation, learning, and enjoyment. The following questions help us understand how your child engages with devices.

What devices does your child have access to? (e.g., mobile phone, iPad/tablet, gaming console, computer)

On average, how often does your child use devices or engage in gaming?

Days per week

Approximate hours per day

What does your child typically use devices for? (tick all that apply)

GamingWatching videos/streamingSocial connection (e.g., messaging, online communities)Learning or educational activitiesCreative activities (e.g., drawing, building, coding)Relaxation or winding downOther (please describe)

How does device use support your child? (e.g., helps them relax, connect with others, engage in interests)

Are there times when transitions around device use (e.g., stopping, limits, switching activities) feel difficult for your child or family?

NoYes (please describe)

How do you currently support your child with transitions or limits around device use?

Do you have any concerns about your child’s device use, or anything you would like support with in this area?

If there anything else relevant to your child of family circumstances that I should be made aware of?

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.

Thank you for your time.