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Childs name Date of birth Address Phone Mobiles Mother

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					Child’s name:                                                          Date of birth:
Address:
Phone:                                             Mobiles:
Mother:                                                       Occupation:
Father:                                                       Occupation:
Email:
School:                                                       Year level:
School contact person:                                        Phone:

Reason for referral




Family details

1. Current family situation


2. Siblings


3. Relevant family history / incidents


4. Parent observations of child’s behaviour etc.




Developmental details

Crawled? (age)                                                Walked?
Spoke in sentences?                                           Read?
Describe gross motor skills
Describe fine motor skills
Describe social skills


2/321 Camberwell Road, Camberwell VIC 3124
telephone: 03 9813 5700 facsimilie: 03 9813 5711
email: info@melbchildrensclinic.com.au
Health details

1. Significant health history




2. Visual assessment ?
3. Auditory assessment ?


Educational details

1. Educational history / progress




2. Present level of academic functioning




3. Social interactions / peer relationships


4. Teacher comments / observations


5. Prior testing? Dates?


6. Results of prior testing


7. Previous intervention / recommendations




Other comments




    I understand that information discussed during sessions will be treated with confidentiality and not disclosed to or discussed
    with schools or other agencies without prior consent, unless somebody is at risk or in danger.
    I have received and agree with the current fee structure
    I have discussed and agree with the proposed outline of services in terms of suggested time frame & objectives

Signed:                                                                            Date:

                                (Please return prior to, or on the day of appointment – with thanks)

2/321 Camberwell Road, Camberwell VIC 3124
telephone: 03 9813 5700 facsimilie: 03 9813 5711
email: info@melbchildrensclinic.com.au

				
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Description: Childs name Date of birth Address Phone Mobiles Mother