CHILD / YOUNG PERSON’S DETAILS Young person’s name Date of Birth Gender---MaleFemale Referred By Medicare Number Expiry Date REASON FOR REFERRAL Reason for Referral REFERRAL + ASSESSMENT HISTORY Name Profession Reason for referral / concern Previous Diagnosis Has your child been previously assessed? Assessment Type Assessed by Date of Assessment SERVICES REQUIRED (PLEASE TICK ONE OR MORE) ASSESSMENTS ASD - Multidisciplinary Assessment ASD - Psychology Assessment Cognitive Assessment Full Educational Assessment Speech Assessment OT Assessment GROUPS The Learning Project Social Groups The Literacy Learning Project School Readiness Program INDIVIDUAL THERAPY Psychology Speech Therapy Occupational Therapy FAMILY INFORMATION Parent 1/Caregivers Name Occupation Date of birth Parent 2/Caregivers Name Occupation Date of birth Address Phone (home) Mobile Email Primary language spoken at home Please list other children in your family Name Age Living with Parent 1Parent 2Both Parents Significant & Relevant Family Factors LEGAL Is the child the subject of any court orders? YESNO PREGNANCY,BIRTH HISTORY AND EARLY CHILDHOOD Were there any complications during the pregnancy? Give details and indicate whether or not the pregnancy was full term Were there any complications during the birth? Did your child require any medical treatment immediately following the birth or within the first few days following delivery? Self-Care and Feeding Skill Approximate age / comment Introduced solids Drank from a cup independently Toilet training Dressing Undressing Do you have any concerns or comments about your child’s eating, drinking or sleeping? Motor Milestones Skill Approximate age / comment Rolled over without help Sat without help Crawled Pulled to stand Stood alone Walked alone Do you have any concerns or comments about your child’s movement? Communication Milestones Skill Approximate age / comment Babbled Spoke first word Used two word phrases Waved hello / goodbye Do you have any concerns or comments about your Child’s communication? MEDICAL HISTORY Current medications. Give list and state reason Significant Illnesses/Dates (Describe) Medical Interventions (Hospitalisations, genetic testing, serious accidents? Accidents/Dates (Describe) Does child/young person have a vision problem? YESNO Does child/young person have a hearing problem? YESNO Permission to contact kinder/school if required? YESNO EDUCATIONAL HISTORY Name of Preschool Name of Middle School Name of Highschool Current year level Other Aide or KIS Support? YESNO Name of Current Teacher Phone number Was there any early intervention involvement (e.g. SCS, Yoralla etc.) Has your child repeated a grade? YESNO If so, has you’re your child ever left a school? If so, why? Please indicate how you feel your child is progressing academically Reading Writing Spelling Numeracy How would you best describe your child? MAIN CONCERNS Communication Recognition of own and other's feelings/moods Self-Esteem/Self-confidence Self-regulation Social Skills and relationship with same age peers and adults Behaviour Fine Motor Skills Gross Motor Skills Memory Do you have any concerns about your child’s attention and concentration? YESNO If yes please provide details Does your child have any sensory issues Other What do you think is the cause of your child’s difficulties? How do you feel your child can best be helped?