Allied Health Intake Form – H2t Allied Health

H2T Allied Health Intake Form

Childs Name

Childs Gender

DOB

Parents/Carer’s Name

Contact Phone Number

What therapies is your child currently receiving

What therapy are you interested in?

Are there any current Child Protection matters involving your child or family? (i.e. physical abuse, violence, neglect, sexualised behaviours between siblings or against minors, exposure to or involvement in domestic/family violence, etc...)

Has your child ever engaged in behaviours (ie through actions or words) expressing that they want to be dead? This includes suicide notes/messages or impulsive behaviours which may result in death or serious injury.

Has your child ever engaged in any self-injurious behaviours (i.e. head banging, biting themselves, cutting, burning, including impulsive behaviours which may result in death or serious injury etc) OR expressed through words that they would like to do so?

Has your child ever disclosed, thoughts, actions or words, intent to cause serious harm to others?

Has your child had an assessment in the past 12 months?

Does your Child have a diagnosis? If so, what is the diagnosis?

Preferred availability

Funding type

Brief description of reasons for therapy

How did you hear about us?

By submitting this Intake form for Head 2 Toe Kids and Family Health, I acknowledge:

All information provided is accurate to the best of my knowledge This referral will be reviewed at time of allocation and may be declined if it is not suited to our service There may likely be a waiting period until I am allocated to a clinician for ongoing support or services (wait times are subject to change, depending on the availability of the clinicians and their varying caseloads) There are NO suicide, self-harm, or risk to others for this referral

H2T Allied Health Intake Form

Contact

Hours

Location

Menu

Subscribe Our Newsletter