Background Information

Child's Full Name *

Child's Date of Birth *

Chronological Age

Address

Street address

City

State

Postcode

Name of Current School

Grade Level

Contact Number

Email Address

Parent/Guardian 1 Name *

Parent/Guardian 2 Name

If separated please indicate

Siblings and other Household Members

Name

Age

Relationship

Live in the house

Paediatrician Name

Paediatrician Contact

Diagnosis

NDIS Number (if applicable)

Presenting Challenges and Strengths

Your impression regarding your child/young person’s challenges is important. Please include as much information as possible as we value parents/carers as being the experts of their child.

What are your current concerns?

What are your child’s interests?

What goals do you have for your child?

Developmental History

Description of pregnancy:

Description of birth:

Description of Infancy:

Developmental Milestones - Ages

Motor skills: (e.g., sitting, walking, running, kicking)

Communication skills: (babbling, saying words, eye contact, playing with friends)

Medical History

Is there a family history of communication/learning/behavioural difficulties? (If so, please describe)

Illnesses/conditions/allergies (please give more details and at what age they occurred)

Has your child had any past diagnoses?

Is your child on any current medications? (please state)

Has your child had their hearing checked recently? (by whom & when)

Has your child had their vision checked recently? (by whom & when)

Academic/Learning

Does your child attend day-care/kindergarten or school? (If so, please state the name and year)

How is your child at school-based skills? (e.g., listening and attending, organising)

Social and Emotional

Has your child ever had behavioural challenges at home/school/kindergarten? (If so, please provide more details)

If yes, what social skills does your child find challenging?

Does your child have any challenges making or keeping friends?

If yes, how does this impact them?

Does your child have any difficulties expressing their emotions or reading the emotional states of others? (please provide details)

Allied Health and Other Services

Health / Education Services

Currently

In the past

Who

Are there any family law court orders we need to be aware of? (Please provide details)

Other Information

Is there any other information that is important for us to know when working with your child and family?

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 and effort in helping us form a holistic and comprehensive picture of your child and family.

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