Child New Client Form - Neuropsych Assessment

Client Information

Please complete the below 'New Client Form' to the best of your ability. If you have any questions regarding anything mentioned in this form, please contact NeuroKids & Beyond for assistance.

Child First Name: *

Child Last Name: *

Child's Date of Birth: *

Child's Gender: *

MaleFemaleOther

Parent/guardian Full Name/s: *

Email Address: *

Residential Address: *

Town *

Postcode: *

Phone Number: *

Is the child currently attending school? *

YesNo

If yes, what is the name of the child's school?

What grade/year is your child in at School?

If funded by NDIS, please state your NDIS Number

Do you agree to NKB receiving a copy of your NDIS Plan

YesNo

If yes, please email your plan to: reception@neurokidsandbeyond.com.au

Medicare details

Child’s number on the card:

Card Number:

Card expiry date:

Parents name:

Parent’s date of birth:

Parents number on card:

Assessment Referral

Who referred the child to our practice? *Please include full name/s

Why were you referred for this assessment? *

Are you funded? (NDIS, Anglicare, DFFH) *

If you are Plan Managed or funded by a third party, please state the name & email of whom we need to invoice. *

Family Medical and Psychiatric History

Child's Mother:

Please complete the below information about to the child's mother.

Mothers Name?

Mothers age?

Mothers Highest Level of Education:

Does the mother have any health problems?

Does the mother have any psychiatric problems?

Child's Father:

Please complete the below information about to the child's father.

Fathers name?

Fathers age?

Fathers Highest Level of Education:

Does the father have any health problems?

Does the father have any psychiatric problems?

Child's Siblings:

Please complete the below information about to the child's siblings.

Does the child have any siblings?

If so, what are the names of the siblings?

Siblings Highest Level of Education:

Do any siblings have any health problems?

Do any siblings have any psychiatric problems?

Extended Family:

Please complete the below information about to the child's extended family.

If yes, please explain:

Developmental History

Where was the child born? *

Were there any complications with the child's birth?

Duration of Labour:

Child's Birth Weight:

Was the child breastfed? *

YesNo

Who provided the greatest support to the mother during the pregnancy and after birth? *

Describe the baby during his/her first 3 months of life (happy, smiling, distressed, cuddly etc.) *

Did the child have any delays in learning to crawl/sit/walk/talk/read/toilet train? If so, please explain

Describe the child during the first 3 years of life:

Please list any other difficulties the child has experienced:

Where did the child grow up? *

Has there been any recent change of locations?

Were there any separations from parent/s or significant others in their first 5 years of life? *

Yes No

If yes, who cared for the child and for how long?

Were there any separations from parent/s or significant others when the child was over 5 years of age? *

Yes No

If yes, who cared for the child and for how long?

Please list all those living with the child/young person (e.g. Parents, brothers, sisters or others): *

List other significant relatives/friends/persons not living with the child/young person (e.g. Parent, Grandparent, uncle, aunt, older siblings): *

If the young person is not currently living with a parent, please describe their current living situation:

If there is an absent parent, please indicate his or her information below:

Academic History

Was your child ever required to repeat a grade in school? *

Yes No

Has your child received special education? *

Yes No

What is the child's highest level of education? *

Medical History

Does the child have any other medical conditions?

Has the child had any prior hospitalizations? *

Yes No

Has the child had a serious head injury? If so, did they lose consciousness?

Does the child regularly exercise? If so, how often? *

If so when was your child’s most recent scan?

Is the child currently on any medication?

If yes, when, where and by who?

Substance Use/Abuse/Dependance

Does the child use cigarettes/tobacco?

Does the child drink alcohol?

Does the child use illicit drugs?

Does the child consume caffeine?

Current Concerns

Have you noticed any problems in the child’s thinking abilities? *

Have they become better, worse, or stayed the same?

Have any of your friends or family members noticed changes in the child?

Have you noticed any changes to the child’s mood?

Have you noticed any changes to the child’s personality?

Has the child ever been hospitalized for a psychiatric reason?

Have the child ever seen a psychiatrist? *

YesNo

Doe the child currently see a psychiatrist? *

YesNo

Has the child ever seen a psychologist/therapist? *

YesNo

Does the child currently see a psychologist/therapist? *

YesNo

How has the child’s mood been? *

Is there any other information you would like to share?

Please tick any Social Groups your child would be interested to attend

Adult Gamers GroupChild Gamers GroupMusic GroupArt Group

Consent

As part of providing a psychology therapy / assessment services to you, NeuroKids & beyond needs to collect and record personal information from you that is relevant to your situation, such as your name, contact information, medical history and other relevant information.

This collection of personal information will be a necessary part of the assessment and treatment that is conducted.

Purpose of collecting and holding information

Your personal information is gathered as part of your assessment and treatment is kept securely and, in the interests of your privacy, used only by NeuroKids and Beyond. Your personal information is retained in order to document what happens during sessions, and enables NeuroKids and Beyond to provide a relevant and informed service to you.

Consequence of not providing personal information

If you do not wish for your personal information to be collected in a way anticipated by this letter or the Privacy Policy, NeuroKids and Beyond may not be in a position to provide the service to you. You may request to be anonymous or to use a pseudonym, unless it is impracticable for NeuroKids and Beyond to deal with you or if NeuroKids and Beyond is required or authorised by law to deal with identified individuals. In most cases it will not be possible for you to be anonymous or to use a pseudonym, however if Neuro Kids and Beyond agrees to you being anonymous or using a pseudonym, you must pay consultation fees at the time of the appointment.

Access to client information

At any stage you are entitled to access your personal information kept on file, subject to exceptions in the relevant legislation. Neuro Kids and Beyond may discuss with your different possible forms of access.

Disclosure of personal information

All personal information gathered by NeuroKids and Beyond during the provision of the service will not be disclosed except when:

1. it is subpoenaed by a court; or

a) failure to disclose the information would in the reasonable belief of the Neuro Kids place you or another person at serious risk to life, health or safety; or

2. your prior approval has been obtained to

a) provide a written report to another professional or agency. e.g., a GP or a lawyer; or

b) discuss the material with another person, e.g. a parent, employer or health provider; or

c) disclose the information in another way; or

3. disclosure is otherwise required by law.

Your personal information is not disclosed to overseas recipients, unless you consent or such disclosure is otherwise required by law. Your personal information will not be used, sold, rented or disclosed for any other purpose.

Fees

The fee of a consultation is payable either prior to the consultation by credit card or bank transfer. If payment is to be covered by a third party these details must be provided as soon as possible, along with acknowledgment by that third party that they will pay the cost of consultation sessions. NeuroKids and Beyond’s Fees schedule is attached.

Cancellation Policy

If, for some reason you need to cancel or postpone your appointment, please email Neuro Kids and Beyond on reception@neurokidsandbeyond.com.au at least 48 hours notice, otherwise you will be charged 50% of the cost for the session.

My medical and contact details to be shared with other appropriate medical services at the discretion of the psychologist with my consent.

*

In the event of an emergency, NeuroKids and Beyond to access appropriate medical care for myself or my child, at my expense.

*

I have read and understood this Consent Form. I agree to the above conditions for the service provided by NeuroKids and Beyond and acknowledge that I have read all relevant information about our service as available on our website or on request.

*

I give consent for the NeuroKids and Beyond Practitioner/Clinician to discuss myself/child with other NeuroKids and Beyond Practitioners/Clinicians at Peer Supervision, Meetings & Clinical Discussions.

*

Signature:

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