Client Details Form

Child's name: *please include first and last names

Date of birth: *

Preferred Name:If your child likes to go by a shortened version of their name or a different name, please let us know

Gender: *

Parent / Guardian 1: *

Parent / Guardian 2:

Parent / Guardian 1 mobile: *

Parent / Guardian 2 mobile:

Relationship to child: *

Relationship to child:

Preference of contact: *

Best daytime phone number: *

Email: *

Street address *

Suburb: *

State *

Postcode: *

Postal address (If different from above):Please write your address, suburb, state and postcode

Siblings:

Who does your child live with:please indicate if living at more than one location

Is there a court order in place? If yes, please list details:

Type of Education: *

Name of Education attended: *

Teacher's name: *

Referred by:

Is your child of Aboriginal and/or Torres Strait Islander origin? *

Is there any religions or cultures that we need to be aware of? *

YesNo

If you answered yes, please let us know what we need to be aware of: *Please answer n/a if you answered no

How will sessions be funded: *

NDIS fundingPaying privately Using your private health fundRebated sessions from Medicare (only possible with an EPC or CDM Plan - please ask your GP for further details)

How is your NDIS funding managed: *

Self managedNDIS managedPlan managedNot applicable (only select this option if you are NOT NDIS funded)

NDIS number (if applicable): *if not applicable, please place a 0 above

Plan Manager Company Name (if applicable): *If not applicable, please write N/A

NDIS Plan Dates (If applicable): *If not applicable, please write N/A

Do you have a NDIS Local area coordinator (LAC)?: *

Other contacts to be listed on file *By adding a contact, you are consenting to Limestone Speech having the ability to communicate with them

Case History

If you are a new client to Limestone Speech, please answer all of the below questions with as much detail as possible.

Does your child have a diagnosis? If yes, please list. *

What concerns do you have about your child's communication/ feeding skills?

When did you first have these concerns?

What concerns do others have about your child's communication/ feeding skills?

What would you like to achieve from speech pathology sessions?

What languages are spoken at home?

What are your child's strengths and interests?

Has your child had their vision and hearing checked? If yes, where and when? What were the results?

Have any family members had any speech, language, hearing, or learning difficulties? If yes, who? Please describe.

Has your child ever received speech pathology services? If yes, where and when? (Please email through any relevant assessments/reports)

Tell me about your child's developmental milestones e.g. sitting, walking, first words, toilet training.

Is there anything we need to know about the birth? (e.g premature, complications etc)

Has your child had any surgery/hospitalisations? If yes, please describe.

Is your child taking any medications regularly? If yes, please list.

Does your child receive other services (e.g. physiotherapy, occupational therapy, psychology)? If yes, please list.

Save and Complete Later