MORE THAN WORDS PROGRAM - INTAKE FORM

Personal Information

Participant/Client first name *

Participant/Client surname *

Date of birth *

Gender *

General Pratictioner or Paediatrician *

Carer Name/s (Who will attend the program?) *

Phone *

Email address *

Home address *

Language spoken at home *

Support Coordinator and Contact (if applicable)

How did you find out about us?

Which of these allied health services has your child accessed before? *

Speech PathologyOccupational TherapyPsychologyBehaviour TherapyNoneOtherMy child is on a waiting list

Please specify what allied health services your child has accessed

Which allied health service/s is your child on a waiting list for?

Communication Information

My child communicates in the following ways (tick all that apply and describe)

Body movements

Examples of body movements

Makes sounds

Examples of sounds

Gestures

Examples of gestures

Reaches

Examples of reaching

Points

Examples of pointing

Looks at me

Examples of eye contact

Imitates/repeats words they hear

Examples of repeating/imitating

Uses single words

Examples of single words

Uses signs, pictures or AAC (tablet/device)

Examples of communication aids

Uses short phrases

Examples of phrases

Uses short sentences

Examples of sentences

My child appears to be interested in communicating with me: *

None of the timeSome of the timeMost of the time

My child understands what is said to them: *

None of the timeSome of the timeMost of the time

What do you want as a CARER to gain or learn from this program? *

What skills do you want your CHILD to improve with this program? *

Any further comments/questions?

NDIS Information (if applicable)

Leave section blank if not applicable.

NDIS number

NDIS Plan Start Date

NDIS Plan End Date

How is it managed?

Self-managedPlan-managedNDIA-Managed/PACE

Plan-manager details (if applicable)

Please attach NDIS goals (if applicable):

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Consent

I confirm that above information I have provided is true, complete and accurate. *

Signature *

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Date *

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