Case History Form

Please complete and submit before assessment.

    DATE
    HEALTH FUND




    Child's name

    Occupation
    Address

    Occupation
    Address





    School/Preschool
    Teacher




    Age first noticed



    Living Situation:  








    YesNoUnsure


    YesNoUnsure


    Does your child wear a hearing aid or glasses?



    YesNoUnsure




    Pregnancy


    Birth

    Birth weight




    Development: Speech

    Babbled (Age)


    YesNo




    Development: Motor

    Crawled (Age)
    Toilet trained - Day (Age)






    NDIS

    Plan dates:



    Agency-ManagedSelf-ManagedPlan-Managed




    PARENT CONSENT FORM

    I consent for Capable Kids South Coast (CKSC) to contact and exchange information with the following services in regards to my child (please tick):
    I also acknowledge I have received, read and consent the CKSC Privacy Policy and Attendance & Cancellation Policy.
    I consent to the use and collection of my child’s personal information.


    Preschool / School teacher / Principal

    Name/ Organisation



    General Practitioner

    Name/ Organisation



    Paediatrician / Other Medical Specialist

    Name/ Organisation



    Other Health Professional (OT, SP, Physio, Psychologist)

    Name/ Organisation



    Plan Manager

    Name/ Organisation



    Case Worker

    Name/ Organisation



    NDIS Contact

    Name/ Organisation




    Signed
    Print Name