Child's Details


Childcare / Kindergarten Details


Background Information

Medical History

Developmental History

Social & Emotional Reciprocity

Non-Verbal Responses

Maintenance of Relationships

Stereotypical Behaviours


Restricted and Fixated Interests

Reactivity to Sensory Input


Collection Statement

Allied Health Services

SASHC is required to collect and record personal information about you and your child in order to provide quality allied health services. This may include assessing, diagnosing and providing therapy. This information is relevant to your child’s situation, such as your child’s name, contact information, medical history and other relevant information as part of providing services to you.  This collection of personal information will be a necessary part of the assessment and/or treatment that is conducted.

Purpose of Collecting and Holding Information

All personal information gathered as part of your child’s assessment and treatment, is kept securely.  In the interest of your child’s privacy this information is only used by your child’s therapist/s and authorised SASHC staff . Your personal information is retained for record keeping purposes and enables your child’s therapist to provide a relevant and informed service to you/your child.  A more detailed description is provided in the SASHC “Privacy Policy”.   This policy is available to you on request.

Access to client information

At any stage you are entitled to access your child’s personal information kept on file, subject to exceptions in the relevant legislation.  SASHC will discuss with you your different possible forms of access.

Disclosure of personal information

All personal information gathered by SASHC during the provision of allied health services will remain confidential, however, please note that by signing and acknowledging this document, you accept that information will be shared with other allied health professionals involved in your child’s care.

Please notify us if you do not wish us to disclose this information or if a child protection/court order is in place.

Audio/Video Recording

As a therapeutic clinic, we often make recordings of sessions and assessments for both analysis and planning. We may also utilise some of these recordings for teaching purposes. Your recordings will be kept secure and will not be shown to individuals not associated with our practice/clinic.

On behalf of SASHC, we undertake that, in respect of any audio/video recordings made, every effort will be made to ensure professional confidentiality and that any use of these audio/video recordings, or descriptions of audio/video recordings will be for professional use only and in the interest of improving professional standards through research and training programmes. Every effort will be made to ensure the anonymity of all those involved in the session.

Information sharing for dual ASD assessments

SASHC is required to share forms and documentation with external assessors, such as ThinkWise Psychology/Tim Dansie Psychology, as required for the purpose of conducting dual ASD assessments.

By checking 'yes' inthe appropriate box below, you acknowledge your decision regarding the sharing of relevant information to facilitate comprehensive evaluations and support for individuals undergoing ASD assessments.

Please be aware that should you chose not to allow information to be shared, a dual ASD assessment cannot be undertaken.

Cancellations/Rescheduled Appointments

Preparation for an ASD assessment is carried out well before the assessment day. Therefore, a non-refundable deposit of $300 is required at the time of booking. If the assessment is  cancelled or  rescheduled within 7 working days of the scheduled assessment date, the deposit will be forfeited.

We strive to send reminders for upcoming appointments; however, it is your responsibility to inform us if you are unable to attend in a timely manner.

Fees and Rebates

Fees Payable

  • If you are a Medicare client, you are required to pay the fee in full on the day of the appointment. Your rebate will be processed through MEDICARE and will be deposited into your nominated bank account within 24 hours of service if you are registered with MEDICARE for rebates. 

  • All private health rebates will be made through HICAPS on the day of the appointment.

  • If you are an NDIS participant and the NDIA does not pay any account associated with the service provided you will be legally responsible to pay SASHC for the unpaid accounts. 

  • Reports of any type will not be released without prior payment.


have read, understood and agree to the above conditions, and as the authorised person, agree to the provision of services by SASHC.

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