Assessment Intake Form

Date

Name of Person Completing this Form

General Information

Patient first name

Patient surname

Date of birth

Country of Birth

Email Address

Home phone

Mobile phone

Home address

Is this person of Aboriginal or Torres Strait Islander Descent?

Are there any cultural or religious requirements we should be aware of?

Name of School and Teacher

How did you find out about us?

Parent/Legal Guardian 1

Name

Relationship to patient

Phone

Email

Preferred Contact Method

PhoneTextEmail

Preferred Days and Hours of Contact

Occupation

Parent / Legal Guardian 2

Full Name

2. Relationship to Patient

2. Phone

2: Email

2: Preferred Contact Method

PhoneEmailText

Preferred Contact Days and Hours

2: Occupation

Legal Agreements / Custody Agreement

Are there any court orders, parenting orders or parenting plans in relation to the patient or access to the patient?

YesNo

Are there any apprehended violence order in relation to the patient?

YesNo

If Yes. Please provide details below

Health Information

Primary Diagnoses

Secondary Diagnoses

Please provide details of your medical team below.

Doctor

Date

Treatment

Does the patient have Epilepsy?

Yes; please provide a copy of the management plan.No

Does the patent have asthma?

YES; if yes please provide a copy of the asthma plan.NO

Does the patient experience anaphylaxis?

YES; if yes please provide a copy of the anaphylaxis plan. NO

Does the patient have a history of Ear infections of Chest Infections?

YesNo

Has the patient had the below inserted or removed?

GrommetsAdenoidsTonsils

When was the last time the patient's vision was tested?

Please list any medications you are currently taking

When was the last time the patient's hearing was tested?

Medications

Dose

Please list any allergies

Allergy

Severity

Please list any surgeries

Surgery

Date

Feeding and Diet

Does the patient have any dietary requirements or challenges?

Did the patient have any early feeding difficulties?

Does the patient have any concerns with nutrition or swallowing?

Does the patient have a mealtime management plan?

Yes; please provide a copy of the mealtime management plan.No

Does the patient require any feeding assistance. Please describe below.

Behaviour Support

Does the patient have a behaviour support plan (BSP) in place

Yes; if yes, please provide a copy of the BSP.No

Does the patient have any form of challenging behaviour? Please describe below.

Is the patient likely to abscond. If yes please describe below.

Support Team

Please outline the patients informal support network below

Does the patient have any formal supports such as support workers involved in their care and development? If so please outline below.

Does the patient have any of the below actively involved in their care?

Occupational Therapist (from another organisation)Speech PathologistPsychologist or CounsellorOther

Details of Occupational Therapist

Details of Speech Pathologist

Details of Psychologist or Counsellor

Others

Development

The following questions were created to range from 0- adulthood. Please only complete the appropriate questions relating to the person you are completing this form about.

Sensory Integration.

Please describe the patient's sensory behaviours in as much detail as possible below.

Please describe any high sensory preferences below.

Does the patient have any sensory seeking or avoiding behaviours?

Please describe any behaviours which you feel are influenced by the patient's sensory integration.

Activities of Daily Living

Please provide as much as detail as possible to support the clinican in understanding current skills.

Toileting. Please describe the patient's ability to complete toileting including if their use nappies and their ability to complete the entire toileting sequence.

Please describe the patient's sleeping including ability to settle to sleep and hours of sleep.

Dressing and Undressing. Please describe the patient's ability to dress and undress including the ability to coordinate dressing, select clothing and place clothing in the laundry.

Please describe the patient's ability to complete showering and/or bathing.

Please describe the patient's ability to brush their teeth.

Please describe the patient's ability to complete hair care.

If completing or using any of the following (menstrual management, deodorant, facial care, make up, piercing management) please describe the patient's ability to complete.

Instrumental Activities of Daily Living.

Please decribe in detail, the skills of the patient to the applicable questions below.

If between 1.5 and 4, please describe the patient's ability to engage with cleaning such as copying cleaning and packing away.

If between 4 and 6 please describe the patient's ability to engage with cleaning and taking care of their belongings.

If between 8 and 12 please describe the patients ability to manage their belongings and complete tasks such as tidying their belongings and room.

If above 12, please describe the cleaning/ household chores the patient partakes in and/or supports required to enable completion of household activities.

Please describe the patient's ability to use technology including use of and charging.

Please describe the patient's engagement with shopping.

Please describe the patient's engagement within the community including activities involved with and behaviours when engaging in the community.

Communication.

Please answer the following questions with as much detail as possible.

Is the patient

Non speakingMinimally speakingSpeaking

If applicable, what are the patient's high interest communication topics?

At what age did you patient start to make cooing or balling noises such as ba-ba or da-da ect.

If applicable, at what age did the patient say their first words and what were they?

If applicable, does the client pronounce words clearly?

If applicable, Does the patient stutter?

If applicable, does the patient ever present with a husky voice or lose their voice?

How would the patient request a need or want?

How would the patient communicate their need for help?

How would the patient communicate their wish for attention?

Please describe below your concerns regarding the patient's communication skills.

Motor Skills.

Please answer the following questions, with as much detail as possible.

Does the patient, use any mobility equipment such as a wheelchair. If so please describe below.

Does the patient appear to like or avoid motor games? Please describe the patient's interest and coordination of motor games such as throwing, kicking, climbing.

Cognition.

Please answer the following questions with as much detail as possible.

Describe the patient's ability to follow instructions such as how many steps can they follow, ability to go between locations to follow instructions and are they able to follow clauses such as first, before ect.

Describe the patients ability to hold attention and to what tasks. General expectation is 2-3 minutes per year of life.

Please describe the patient's ability to problem solve

Please describe the patient's memory.

Please describe the patient's ability to manage multiple things at once.

Are you worried about the patient's receptive language and ability to understand or comprehend? Please describe your concerns.

Social and Emotional Skills.

Please answer the following questions with as much detail as possible.

What and How does the patient enjoy to play?

How does the patient express their feelings or emotions?

Describe any fears or phobias the patient has below.

Describe the patient's sense of danger below.

What would the patient be highly driven to complete and what would they have no motivation or drive to action?

Please describe the patient's ability to make and maintain friendships.

Describe the patient's interpersonal skills such as social reasoning and understanding of social emotions below.

Person Attributes

What are the patients favorite activities or interests?

What are the patient's strengths and talents?

Service Management

Does the patient have a case manager or support coordinator. Please provide the details below.

Will the patient's services be funded by the National Disability Insurance Scheme?

Yes; if yes please complete the following questionsNo

What is the patient's NDIS Number?

What are the NDIS Plan Dates?

The patient has an NDIS Plan and it is

Self ManagedPlan Managed; if you are plan managed, please provide the details of the plan management company below.NDIA Managed

Plan Management Company Details

Please provide a copy of your NDIS Plan to enable Transforming Kids to understand your NDIS Goals. Providing your full plan is helpful for planning for NDIS Reviews and ensuring we can asisst with funding questions, however not necessary.

Referral Details

Why are you seeking an assessment?

What are you hoping to achieve from this assessment?

Privacy Consent

Transforming Kids needs to collect information about the participant for the primary purpose of providing a quality service to you. In order to thoroughly assess and provide appropriate support services to you, we need to collect some personal information from you. If you do not provide this information; we may be unable to offer services to you. This information will also be used for:

The administrative purpose of running the service;

Informing program design of Transforming Kids Therapy Services

Supplying ongoing support (including making this form available to relevant workers

Disclosure of information to your NDIS plan manager, doctors, teachers or specialists as required to facilitate communication and best possible support for you.

We do not disclose your personal information to overseas recipients.

Transforming Kids has a Privacy Policy that is available on request and within our welcome pack. That policy provides guidelines on the collection, use, disclosure and security of your information. The Privacy Policy contains information on how you may request access to, and correction of, your personal information and how you may complain about a breach of your privacy and how we will deal with such a complaint.

Transforming Kids has Cameras within each therapy room which record provision of services; this allows clinicians to review service provision and perform quality management reporting. If you do not want to be videoed, you can opt out below.

To ensure the process of quality service provision, information about your progress may be given to other relevant service providers, who are involved in your support management. These may include your NDIS plan manager, doctor, teachers or specialists.

I have read the above information and understand the reasons for the collection of my (or patients) personal information and the ways in which the information may be used and disclosed, and I agree to that use and disclosure. *

I understand that it is my choice as to what information I provide, and that withholding or falsifying information might act against the best interests of my support.

*

I am aware that I can access my (or patient's) personal on request and if necessary, correct information that I believe to be inaccurate. *

I understand that if, in exceptional circumstances, access is denied for legitimate purposes, that the reasons for this and possible remedies will be made available to me

*

I understand I can find the full Transforming Kids Privacy Policy on their website tteam.com.au

*

I understand that Transforming KIDS Uses CCTV Video recoding within clinic for supervision purposes and incident management. This enables the clinician's supervisor to review video footage, ensure quality service provision and investigte incidents (if they occur). No Video is stored of clients but I can opt out below If i wish.

I understand I can opt out of CCTV Video recording within clinic by selecting the option to the Right.

*

I choose to:

I am a Human *

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