Child Intake Form

This information you provide on this form will be kept confidential. You may contact us at any time to request a copy of the information you have submitted to us. Please refer to our privacy policy for more details on how we store, use, and protect data here. Feel free to skip any questions you feel are not relevant or you would rather not answer.

Today's date *

Your name, highest level of education, occupation, and relationship to the child *

Your home address including street name and number, locality, and postcode *

Child's name, birthday, age, and gender *

Name of School, Kindy, Early Childhood Centre, Playcentre, etc. *

Names of any other parents or guardians *

Are there any custody or family arrangements that we should be aware of? *

Names and ages of any other children in the home *

Is there anything you would like us to know about your culture, ethnicity, or values and beliefs? *

Does the child understand or speak any other languages besides English? Are there other accents of English that they are familiar with? *

What are the child's regular communication environments? For example: school, grandparents, sports practice, dance, scouts, etc. *

Has the child been previously seen by a Speech-Language Therapist? If so, would you give us permission to contact them? This allows us to coordinate care and also avoid repeating unnecessary assessment procedures. *

What is going well / not going well for the child in terms of oral language, literacy or communicating? *

What are the impacts of these difficulties and what is your priority for intervention? *

Does the child have any known disability, speech-language, or medical diagnoses that we should be aware of? *

Does the child have any allergies or other medical needs that we should be aware of? *

What makes the child light up? It really helps us to know what the child loves to do or talk about. *

When the child is upset, what have you found helps calm them down? *

Early years

School years

Is the child currently receiving any support from other professionals or organisations? For example, physiotherapy, occupational therapy, Ministry of Education Learning Support, private tutoring, music therapy, counselling,etc. *

Do you need help with accessing any services? *

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