Welcome to Side By Side Therapy Please fill out the form below to get started. Step 1 of 12 8% PRIVATE AND CONFIDENTIAL - SENSITIVECLIENT INFORMATIONName of person completing this form:(Required) First Last Relationship of person completing form to child:(Required)Child's name:(Required) First Last Child's preferred name:Child's gender:(Required) M F Other Preferred pronoun: He/Him She/Her Them/They Other Child's date of birth:(Required) DD slash MM slash YYYY Child's place of birth:(Required)Child's nationality:(Required)Does your child identify as: an Aboriginal person a Torres Strait Islander person Prefer Not to Say Primary language spoken at home:Other languages:Child's primary address:(Required) Street Address City State / Province / Region ZIP / Postal Code CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Primary email address for contact:(Required) Primary phone number for contact:(Required)Emergency contact person:(Required)Emergency contact number:(Required)Does your child have a specific diagnosis?(Required) Yes No If yes, what is the specific diagnosis or diagnoses?How did you find out about Side by Side Therapy? NDIS INFORMATIONIs your child registered with NDIS?(Required) Yes No If no, are you planning to have your child registered in the future? Yes No If yes, please provide the NDIS number:(Required)NDIS plan dates:(Required)How is your child’s NDIS plan managed?(Required) Self-Managed Plan Managed Please provide the email address for invoices:(Required) Is your child’s plan for early intervention (usually for under 7s)?(Required) Yes No MENTAL HEALTH CARE PLANDoes your child have a Mental Health Care Plan?(Required) Yes No Has a referral been sent? Yes No Unsure Referral date: DD slash MM slash YYYY Referring GP:Referring Clinic:Provisional diagnosis: OPEN ARMS (VETERAN AFFAIRS)Does your child have an Open Arms referral? Yes No DEPARTMENT OF CHILD PROTECTIONDoes your child have a Department of Child Protection referral? Yes No OTHER REFERRAL FUNDINGDoes your child have a referral and/or funding not listed? Yes No Please give details PURPOSE OF SUPPORTWhat concerns do you have about your child? General mental health issues Anxiety Depression Difficulty making or keeping friends Low self confidence Attention issues Communication challenges Sensory issues Gender or identity challenges Low self esteem Emotional regulation Behaviour issues Easily frustrated Possible trauma Lack of organisation Social interaction Memory or learning challenges Play skills Attachment difficulties Anger issues Other: If your child has sensory differences, how do they affect day-to-day functioning?What are you hoping to get from therapy at Side by Side?Are you willing to participate in sessions with your child? Yes No Unsure at the moment When were your child’s difficulties first observed?Please provide any additional details or concerns:RISK ASSESSMENTPlease check all that apply:(Required) Suicidal thoughts Suicidal intent/plan Self-harm Risk to others Risk of property damage Risk of absconding (running away) None of the above If your child is experiencing serious distress or is at immediate risk of harm, please call 000 or present at Emergency at your nearest hospital. Side by Side Therapy does not offer crisis services. DEVELOPMENTAL HISTORYIs your child adopted? Yes No Is your child fostered? Yes No Are there custody arrangements in place for your child? Yes No If yes, please describe:Please describe anything unusual about your child’s infancy or development: MILESTONESSitting Early Normal Late Unsure Crawling Early Normal Late Unsure Walking Early Normal Late Unsure Skipping/running Early Normal Late Unsure First words Early Normal Late Unsure First sentences Early Normal Late Unsure Clear speech Early Normal Late Unsure MEDICAL HISTORYDoes your child have:Allergies? Yes No Comments:Glasses? Yes No Comments:Hearing loss or hearing aids? Yes No Comments:Recurrent ear infections? Yes No Comments:Serious illness or injury? Yes No Comments:Seizures? Yes No Comments:History of mental distress? Yes No Comments:Behaviours of concern? Yes No Comments:Please list any medication your child is currently taking:Please describe any other medical conditions or medical information you feel is significant:Sleep HabitsApproximately how many hours does your child sleep per night?Does your child fall asleep easily? Yes No Does your child sleep soundly? Yes No Does your child have sleep difficulties? Yes No Does your child sleep alone? Yes No Sometimes Does your child sleep in own room? Yes No Sometimes Does your child share a bedroom? Yes No Please describe any sleep difficulties: FAMILY HISTORYDoes your family have a history of any of the following? If yes, please provide details in the comments section.Dyslexia (or reading/spelling difficulties) Yes No Comments:Learning disabilities Yes No Comments:ADHD/ADD (hyperactive-impulsive, inattentive or combined) Yes No Comments:Speech/language delays Yes No Comments:Chronic illness Yes No Comments:Autism, including Asperger’s Yes No Comments:Developmental delay Yes No Comments:Neurological disorders Yes No Comments:Mental health issues Yes No Comments:Trauma Yes No Comments:Significant illness or injury Yes No Comments:Significant loss Yes No Comments:Recent significant change Yes No Comments:OtherPlease list the members of your child’s householdIs your child a member of more than one household?(Required) Yes No If yes, please provide details:Are there any current custody agreements or court orders in place?(Required) Yes No If yes, please provide details: ACADEMIC HISTORYIf your child does not yet attend school, please fill in for kindy or day care. Leave blank if not applicable.What school, kindy of day care does your child attend?Year or level:Number of years at current school, kindy, or day care:Has your child recently moved schools? Yes No Does your child receive in-school learning support? Yes No If yes, how many hours per week?Is your child able to finish work in class? Yes No Is your child able to participate in a full school day? Yes No Is your child able to work independently? Yes No Is your child able to keep on task? Yes No Is your child able to complete homework? Yes No Is your child able to stay seated? Yes No Is your child able to enjoy school, kindy, or day care? Yes No Is your child able to ask for assistance? Yes No Is your child able to work in a group? Yes No Is your child able to make friends? Yes No Is your child able to play alone? Yes No Describe your child’s school experience: OTHER SERVICESHas your child ever received, or is your child receiving, any of the following? Please provide details such as where, therapist details, years attended, if still receiving services, reasons for discontinuing, if on waitlists etc.Speech and Language Therapy Yes No Details:Occupational Therapy Yes No Details:Physical Therapy Yes No Details:Special Education Yes No Details:Psychological (Mental Health) Counselling or Therapy Yes No Details:Behaviour Therapy Yes No Details:In-school Learning Support Yes No Details:Other: SOCIAL/EMOTIONAL HISTORYDescribe your child’s friendship situation:What is the preferred age of your child’s friends (older, younger)?How does your child get along with other children?Describe your child’s sibling relationships:Describe your child’s attitude towards responsibilities:Describe your child’s attitude towards his/her/their difficulties:Describe any family stresses such as divorce, illness, death, moving etc.Describe how your child's challenges affect the family as a whole:Describe any unusual behaviour patterns observed in your child:Describe your child’s personality:Describe your child in three words:INTERESTS, ABILITIES, ACTIVITIESDescribe your child’s strengths:What are your child’s extracurricular activities?What are your child’s hobbies and interests?If you have told your child about potentially attending therapy sessions, what have you told them, and what was the response?Provide any additional relevant information not mentioned:I declare the above information is correct, to the best of my knowledge, at the date below. I agree to inform Side by Side Therapy if there are any changes to the above.(Required) Yes I give permission for a placement or work experience student to sit in on sessions(Required) Yes No I would consider support from an Allied Health Assistant rather than, or in addition to, a fully qualified practitioner(Required) Yes No I would like to go on the Side by Side Therapy mailing list(Required) Yes No I give permission for this information to be shared with the Side by Side team for clinical, learning, supervision, and/or administration reasons(Required) Yes No I understand that intake sessions are invoiced and payment is required for non-attendance where less than 48 hours notice is given.(Required) Yes Name(Required) First Last Signature:(Required)Please note that a typed name is considered a signature for the purposes of this form.Date(Required) DD slash MM slash YYYY CommentsThis field is for validation purposes and should be left unchanged.
