CDSP | Paediatric Assessment Registration Form

Paediatric Assessment Registration Form

To make an appointment for your child, please fill out all required fields on the paediatric assessment registration form below, and sign the form before submitting. We will be in touch soon after we receive your child’s registration form to arrange a suitable appointment time.

Child's Name *

First

Last

Date of Birth *

Street Address *

NDIS Participant? *

If yes, NDIS number:

Diagnosis (if applicable)

Name of siblings and their ages? *

e.g. Rebecca Bink 3, Elijah Bink 6, David Bink 10 (NIL for none)

Name of current school and year level: *

Family Details

One parent/guardian's full set of details must be filled out on the form. If child is living with both parents/guardians, full details of both parents/guardians are required.

Parent/Guardian 1

First

Last

Parent/Guardian 1 Phone Number

Best contact number

Parent/Guardian 1 Email Address

Parent/Guardian 2 Name

First

Last

Parent/Guardian 2 Phone Number

Best contact number

Parent/Guardian 2 Email Address

Are there any relevant court orders in place? *

if yes, please provide more information.

e.g. separated, divorced etc.

What is your child’s favourite cartoon character or topic of interest? *

Any family history of speech, language or communication problems? *

If yes, provide details

Communication History

What is your biggest concern about your child's communication? *

Has your child been hearing tested?

If yes, provide details

Did your child babble as a baby? *

If yes, provide details

Does your child say... *

Single words
Two word sentences
Three word sentences
Four + word sentences?

Please select all answers that apply

Please provide details *

Can your child follow... *

One step instructions? e.g. "Put your hat on"
Two step instructions? e.g. "Put your hat on and sit in the car"
Three or more step instructions? e.g. "Put your hat on, brush your teeth, sit in the car"

Please select all answers that apply

Please provide details *

What percentage of your child's speech do you understand? *

Provide your best estimate. e.g. 50%

Does your child... *

Make eye contact?
Understand what you say?
Use gestures or body language?

Please select all answers that apply

What percentage of your child's speech do others understand? *

Provide your best estimate. e.g. 50%

How does your child currently communicate? *

List all methods. e.g. talks, grunts, points, uses gestures or a sibling to talk to him/her.

Does your child experience difficulties in communicating with peers and/ or teachers? *

If yes, provide details?

Are there any difficulties with eating and/drinking? *

e.g. coughing, choking or gagging?

If yes, provide details?

Medical History

Any significant pre-natal or birth issues (e.g. neonatal intensive care)?

If yes, provide details

Any surgeries or hospitalisations? *

Describe surgeries and/or hospitalisations if any?

Any current medication? *

if yes, list all current medication

Name and profession of treating specialists? (e.g. neurologist, psychologist, geriatrician) *

if none answer 'NIL'

Assessments

Please indicate the assessment/s you feel you might need *

Speech only (e.g. the way words are spoken and speech sounds are made)
Language only (e.g. using and understanding words and sentences)
Fluency only (e.g. you are concerned that your child may be stuttering)
Educational Assessment only (e.g. reading, literacy, decoding/understanding written text)
Speech and language
Speech, language and education

Select one of these options.

Source of referral (e.g. paediatrician) *

Consent

To give consent for the following, check the tick boxes below

I give my full consent for the following: *

CSDP making an audio recording of your child's assessment for the sole purpose of analysing his/her speech and/or language.
CDSP contacting your child's teacher for further details.
CDSP sending your child's assessment report via email.
CDSP providing information to, and receiving information from other relevant professionals e.g. paediatrician.

Please tick all the checkboxes you agree with.

Would you like your child to be screened for social difficulties that may be associated with Autism Spectrum Disorder? *

If yes, no additional cost applies.

Terms of Service Agreement

1. The consultation is for assessment only.
2. Payment is due at the time of consultation – EFTPOS or direct bank deposit only.
3. Current fees for professional services are:

* Speech OR language OR fluency assessment with report - $400
* Speech AND language OR fluency assessment with report - $600
* Educational assessments – POA

4. Payment is the responsibility of the person making the appointment - invoices will not be issued to the NDIS, insurance companies or other third parties.
5. Cancellation of a scheduled appointment requires 48 hours notice. Cancellations received within 48 hours of the scheduled start time will incur a 50 percent cancellation fee. Appointment no-shows will incur a 100 percent cancellation fee. Please refer to our Cancellation Policy for further information.
6. Mobile phones are to be turned off during the consultation.
7. Upon receipt of this form, you will be notified and will be offered an appointment as soon as possible.

By signing below I state that I have read, and agree to the 'Terms of Service Agreement'.

Todays Date *

e.g. 24/1/2021

Full name of person filling out this form *

Relationship to the child *

eg, mother, father, guardian

Signature *

Clear Signature

Please sign here.

Captcha *

Paediatric Assessment Registration Form

Family Details

Communication History

Medical History

Assessments

Consent

Terms of Service Agreement

Postal Address

Pin It on Pinterest