Parent or guardian details

We use these details to contact you about this enquiry.

Full nameRelationship to childEmailTelephone numberHome addressCity / AreaPostcode

02

Child details

Basic information for the intake review.

Child’s full nameMyKid No. (if available)Date of birthAutomatically calculated ageGenderPreferred languageCitizenshipRaceReligionAllergiesAllergy details, if anyOKU Card No. (if any)

Emergency contact

Full nameRelationshipTelephone number

03

Diagnosis and therapy history

Select all that apply; no need to type each item.

Current school or programmeTherapy centre / duration details

04

Developmental, medical and social history

A concise history to help the therapist prepare.

Developmental milestones

Crawling age (months)Walking age (months)First words age (months)Self-feeding age (months)

Medical history

Pregnancy and complications, if anyBirth termDelivery typeBirth weightHospital admission historyOther medical conditions / current medication

Social and family history

Child lives withInteraction with other childrenFamily history of developmental/learning difficultiesIf yes, please specifyBehavioural or sensory concerns

05

Needs and preferences

Tell us what you would most like to discuss.

Preferred branchService interested inPreferred appointment timeMain developmental concernsWhat would you most like your child to achieve?How did you hear about Kidsaurus?

06

Consent

Please review before submitting.

I consent to the collection and use of this information as described in the Privacy Notice.I agree to be contacted about this enquiry and relevant services.I consent to communication through WhatsApp.Optional: I consent to authorised care-related use of photographs or documents. Detailed consent will be obtained separately where required.