SPEECH PATHOLOGY CASE HISTORY QUESTIONNAIRE

Child's Details

Child’s Surname *

Given Names *

Date of birth: *

Gender

MaleFemaleOther

Parent/Caregiver’s Name(s) *

Mobile Phone

E-mail Address

Address *

Street address

Suburb

State

Postcode

Name of Emergency Contact

Emergency Contact Phone Number

Relationship

Medicare

Parent's Medicare Number *

Child's Reference Number on the Card (e.g. 1, 2) *

Parent's Full Name as on Medicare Card *

Medicare Expiry Date *

Parent's Date of Birth for Medicare Billing *

School Details

Child's Childcare/ELC/Kindergarten/School Name

Year Level/Grade (if at school)

Teacher/Educator Name

Referral

Was your child referred for speech pathology?

YesNo Self-referral

If yes, who referred your child for the test?

What were the concerns that resulted in a speech pathology session being booked?

Birth History

Was there anything unusual about the pregnancy or birth?

YesNoUnsure

If yes, please describe

Were there any birth complications?

YesNoUnsure

If yes, please explain

Family History

Who lives at home with your child? (please list all names, including siblings and their ages)

What languages are spoken at home? Please list

Do any family members have a history associated with

SpeechLanguage orHearing

If yes, please explain (speech, hearing, language)

Are there any culture, values, or beliefs your family has we should be aware of?

YesNo

If yes, please explain

Medical History

Has your child been diagnosed with any conditions?

YesNoUnsure

If yes, please list diagnoses and date of diagnosis (is possible)

Did your child pass their Universal Neonatal Hearing Screen (hearing test at birth)?

YesNoUnsure

If no or unsure, was this followed up? Please explain

Has your child had a hearing test since the UNHS test?

YesNoUnsure

If yes, what was the outcome of this test?

Has your child had any major medical issues or needed to be on any medications for long periods of time?

YesNo

If yes, please list the medications

Developmental History

At what age did your child start to sit up unassisted?

At what age did your child walk unaided?

At what age did your child say their first true word?

At what age did your child start to put 2 or more words together?

Has your child ever had any difficulty eating (chewing, swallowing, stuffing, pocketing, picky, food aversions, cup use etc.)?

YesNoUnsure

If yes or unsure, please describe

Play and Social Skills

What does your child enjoy doing/playing with?

How would you describe your child's personality?

Does your child prefer to play alone?

YesNo Maybe

If yes or maybe, please explain

Does your child have unusual interests (likes playing with strips of paper, lining toys up etc.)?

YesNoMaybe

Does your child have unusual interests?

Educational History

If yes, please list the name of the organisation

Has your child ever repeated a level of education (e.g. kindergarten, preschool, year 1 etc.)?

YesNoToo young

If yes, please explain (repeated school)?

If yes, please explain (literacy issues)

Have teachers/childcare staff ever expressed concerns regarding your child's learning or development?

YesNoNot applicable

If yes, please explain (teacher concerns)

Medical and Allied Health Professionals

Please list the professionals inolved in your child's care ( please provide their names and practice details i.e. company names)

G.P./ Family Doctor

Paediatrician

Speech Pathologist

Occupational Therapist

Physiotherapist

Ear, Nose and Throat (ENT) Specialist

Please list other professionals not mentioned above who are involved with your child's care

General

What are your child's strengths?

What are you most concerned about with regards to your child's development (please list 3 concerns)? *

Please list 3 goals you would like your child to achieve from speech therapy *

Please add anything further you feel the speech therapist may need to know about your child

Session Preferences

How often would you like to have speech therapy sessions? *

Do you have a preferred time of day for speech therapy sessions? Please note them here

What is your preferred location for speech therapy sessions? *

Clinic-based (sessions conducted on-site at SASHC)Home Childcare/ELC/Kindergarten/School

If external location selected, please provide the address (and name of the organisation if applicable)

Please note that all external speech therapy sessions will incur a travel fee. In the interest of providing the best possible service to our patients, we limit travel to 10km from our clinic. We will provide you with a quote for travel and speech pathology sessions prior to commencing therapy sessions.

Payment Options

If Other, please list funding option

If NDIS plan-managed, please provide further details

Plan Manager Name

Plan Manager Phone Number

Plan Manager E-Mail Address

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.

Do you agree with the audio/visual statement above? *

YesNo

Cancellations

Self-funded appointments

The Provider will send out reminders for all scheduled appointments, however, no shows and appointments cancelled within the short notice period (defined by the Provider as notice of less than 48 hours from the scheduled appointment time slot) from the scheduled time will incur a fee of 100% of the agreed fee.

NDIS appointments

We understand that at times appointments will need to be cancelled due to illness and unavoidable circumstances. However, in order to provide an affordable and viable service, SASHC has adopted the following cancellation policy in line with NDIS policy.

We will send out reminders for all scheduled appointments, however, no shows and appointments cancelled within the short notice period (defined by the NDIS as less than 2 clear business days) from the scheduled time will incur a fee of 100% of the agreed fee associated with the activity from the Participant's plan.

Late attendance

We make every effort to send out appointment reminders, and we ask that you respect our clinicians time. Arriving late not only impacts your appointment but also those of other patients scheduled throughout the day. Consequently, we are unable to complete full assessments for late arrivals. Therefore, patients who arrive 10 minutes or more past their scheduled appointment time will not be seen and a full appointment fee will be charged.

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.

Consent

I (please print name) *

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

Signature *

Draw signature|Type signatureClear

Date *