Service Enquiry Form Service Enquiry Form Information about your childName* First Last Date of Birth* DD MM YYYY Age*Have you attended Skills for Kids before?*NoYes, with this childYes, with another childName of ChildHas someone recommended that you contact us?*YesNoA. Please tick the appropriate box* School Paediatrician Psychologist Family Doctor Other B. Name of PersonC. Why did they recommend that you contact us?What are your concerns and/or questions about your child?*Services you are enquiring aboutWhat services are you enquiring about on behalf of your child? Please tick all that apply. Occupational Therapy assessment Occupational Therapy Session Speech Language Pathology assessment Speech Language Pathology session Camp Information about parentsParent 1* Mr.Mrs.MissMs.Dr.Prof.Rev. Title First Last Parent 1 mobile*Email* Mailing Address* Street Address Suburb/Town Post Code Parent 2 Mr.Mrs.MissMs.Dr.Prof.Rev. Title First Last Parent 2 mobileInformation about your child's preschool or schoolPreschool / School nameIf Preschool, which year do you expect your child will commence Kindergarten?If at school, what grade is your child currently in?In order to gather information about your child’s performance in a ‘real world’ context and not in the isolation of our tasks, we typically forward a questionnaire to your child’s teacher. Do we have your permission to do this?*YesNoTeacher's NameTeacher or School Email Information to help us identify your child's needsBelow are 2 lists of areas in which some children have difficulty. One is for Occupational Therapy. One is for Speech Language Pathology. - If you think your child may need Occupational Therapy, please tick the relevant boxes. - If your think your child may need Speech Language Pathology, please tick the relevant boxes. - If you think your child may need both, please tick boxes for both. It is OK to tick as many boxes as you need. Occupational Therapy Fine Motor (Colouring, cutting, drawing) Handwriting (Legibility and speed) Writing (‘Brain to paper’ for organisation quality and quantity) Special provisions (For examinations e.g. extra time, rest breaks, typing) Personal care (Dressing, eating, toileting, hygiene) Gross Motor (Ball skills, sport, coordination) Social (Making friends, keeping friends, appropriate and expected behaviours) Emotional (Self-regulating feelings such as anxiety, anger. Being resilient.) Play (Playing with imagination / in a purposeful way / cooperatively with other children) Physical (Hand dominance, pencil grip, finger dexterity) Sensory Processing (Being overwhelmed by too much confusing visual distraction, sound, movement stimuli; not coping with wearing clothes with certain textures, eating food with certain tastes, coping in noisy environments such as shopping centres, coping with hair brushing / teeth cleaning) Eye hand coordination Attention (Staying focused, focusing without being distracted, focusing on important detail) Memory (Being able to hold in mind a number of items at the same time e.g. following instructions) Planning, sequencing, prioritizing Decision Making Problem Solving I don't know Other Please SpecifySpeech Language Pathology Articulation / Speech (Being able to be understood, using tongue and mouth to make and sequence sounds and words) Receptive language (Being able to understand what is being spoken or read in spite of level of intelligence.) Expressive language (Being able to communicate thoughts and feelings) Literacy (Being able to process language for reading, writing and spelling) Phonemic awareness (Being able to sequence sounds inside words for reading, writing and spelling) Stutter (Being able to speak without repeating sounds or words) Pragmatics (Being able to communicate socially e.g. conversation) Language stimulation (For children who are young and not yet using language to communicate) Selective mutism (For children who choose not to talk in certain contexts) I don't know Other Please SpecifyOther valuable informationDoes your child have a diagnosis?*NoYesPlease ListHas your child had a vision assessment?*NoYesWhat were the results?Has your child had a hearing assessment?*NoYesWhat were the results?Do you have reports from any previous assessments? e.g. psychologist, paediatrician, school counsellor, previous speech language pathologist, previous occupational therapist:*No, I do not have any reportsYes, I have reports and I will provide them at the assessmentDoes your child have an NDIS plan?NoYes, I will provide a copy of my child's NDIS Plan once services have been organisedPayment: Please advise who will be paying for services so that we can bill correctly. Parents Funding agency such as Barnardos, Anglicare, Wesley Mission Family and Community Services NDIS What else would be helpful for us to know about your child and/or your family?