Group Case History Form

GROUP ENROLMENT FORM

All information provided on this form is strictly confidential & will become part of your client record. This is a general form for a wide variety of groups. Some questions might not apply to your child - this is for us to gauge their suitability for certain groups.

Registration Information

Child's First Name *

Child's Surname *

Preferred name

Date of Birth *

Gender *

Male Female Other

Primary Language spoken at home *

Address *

State *

City / Suburb *

Postcode *

How did you hear about us? *

(Other) Please Specify: *

Primary contact first name *

Primary contact last name *

Primary contact relationship *

Mobile number *

Email Address *

Secondary contact First Name

Secondary contact last name

Secondary contact relationship

Mobile Number

Email address

Who lives at home? *

Family Status (eg: married/separated/divorced) *

Are there additional carers who provide regular care for your child?

Are there any Legal or Court agreements? *

YESNO

Details of Legal/Court Agreements *

Funding *

Private/no fundingNDIS Self-managedNDIS Plan managed

Groups cost the same for all funding types. You will receive a Service Agreement detailing fees prior to your first session. There are no Medicare rebates for group sessions.

Communication

What is your preferred method of communication for session feedback? *

In PersonEmailPhone Call

Would this method change if handover is not possible in person?

YESNO

Do you want separate communication to both parents? *

YESNO

Diagnosis

List any diagnoses and age at diagnosis

Medication (If any)

Current Intervention- When ticking yes please provide copies of recent reports or assessments

Does your child have any hearing difficulties?

Speech Pathology Assessment and/or Therapy:

YESNO

Date or Year Seen?

By Whom?

Is It ongoing?

YESNO

Occupational Therapist seen?

YESNO

Date or Year Seen?

By Whom?

Is it ongoing?

YESNO

Psychological Assessment:

YESNO

Date or Year Seen?

By Whom?

Any further information you want to provide?

Medical History

Ear InfectionsVision DifficultiesHearing Difficulties

Please list any major illness or health problems

Has your child attended group sessions before? *

YesNo

If so where?

Please describe how your child went during these sessions (behaviour, enjoyment, engagement, was it successful? Why/why not?) *

Behavious/Attention

Do you have concerns regarding your child’s behaviour or ability to concentrate? *

YESNOUnsure

Please describe: *

Other/please list

Education

Education/Childcare Institution

Grade Level/Year Level

Teacher’s Name

School/Kindergarten Observations

Please describe how your child behaves with external care. *

What are they like in the playground?

What are they like during group time?

Do they require any extra classes or support? If so, what? Do they have an aide?

Able to use pencil/pen, able to use scissors, can sit at a table for more than 5 minutes?

Sensory Needs - Aversion to loud noises, repetitive behaviour patterns, sensory seeking behaviours such as always moving, constantly running/jumping/spinning, always touching items

Social Skills - E.g. Difficulty maintaining eye contact, staying on topic or taking turns in conversation, ability to recognise emotions

Play E.g. Solitary play, with children or adults majority, turn taking in play, sharing in play

Speech/Articulation of speech sounds E.g. Difficult to understand due to leaving out or changing sounds. Can you understand your child’s speech?

Understanding of language E.g. Difficulty following instructions and understanding concepts. Child may need repetition of instructions or clarification.

Expression of language E.g. Difficulty using/forming sentences to express ideas; gives short, sometimes incomplete responses to questions. How many words does your child use?

Self-regulation and Emotional regulation - E.g. ability to recognise emotions, large emotional responses, ability to take on a challenging task, self-confidence, meltdown frequency

If your child experiences meltdowns, briefly describe what this looks like for your child

Routine

Do you have a daily routine?

YesNo

Do you have difficulty changing the routine for your child?

YesNo

If yes, please describe

What level of supervision does your child need? Eg do they wander, go with strangers, aware of traffic, take unsafe risks, do they require constant supervision to maintain safety?

What do you want your child to achieve from a group session? Do you have any specific goals for your child? *

Briefly list your child’s main interests

Name of the person completing the form *

Date *

Your Email *