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Thank you for taking the time to complete this document. Your clinician, and All About Kids, will
appreciate your information. Please read and fill out the whole document where relevant, and
sign at the bottom of page 8.

Caregiver Questionnaire

Your Childs Details:

First Name: ____________________________ Surname: ________________________________

Date of birth: __________________________ Male Female Other:_________________

Current School/ Childcare / Kindy: ___________________________________________ Year level: ________

Medicare No: ________________________________________ Medicare Expiry No.: ________ Childs Ref. No: _______

Main Claimant's (Guardian) Ref. No:__________ Main Claimant's (Guardian) Date of Birth: _______________

Family Details
If separated please indicate If you have court orders please provide a copy for your clinician.

Caregiver 1 Name:_______________________________________ Occupation:______________________

Home Address: _______________________________________ (Suburb)____________ (Postcode) __________

E-mail ________________________Telephone: (Home) ________________ (Mobile): ______________________

Caregiver 2 Name: _______________________________ Occupation:__________________________

Home Address: _______________________________________ (Suburb)____________ (Postcode) __________

E-mail ________________________Telephone: (Home) ________________ (Mobile): ______________________

Siblings: Name: _______________________ Age: ______ Sex: ________ Resides with: ___________________

Siblings: Name: _______________________ Age: ______ Sex: ________ Resides with:____________________

How can we support you?

Describe your concerns or the reason for seeking support (give a brief description of your child’s behaviours, symptoms, difficulties)
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

Overall, how concerned (worried) are you about your child?

Not at all A little Moderately Quite a lot Extremely
Caregiver 1 1__________2___________3___________4___________5

Caregiver 2 1__________2___________3___________4___________5

What would you like your child/ren to work on in therapy? ________________________________

What would you like to work on in relation to your child/ren? ________________________________

What (if any) things would you like to work on as a couple/ individual?________________________________

Clinic: Shop 2, 33 Lisson Grove Wooloowin, 4030 (07) 3262-6009

reception@allaboutkids.com.au www.allaboutkids.com.au
Clinic: 6 A Mecklem Street, Strathpine, 4500 (07) 3132-3085
 2 of 8

Developmental / Medical History

General information regarding health of your child that may have or be influencing behaviour – any medical diagnosis –
When? By whom? Any medication?

__________________________________________________________________________________
__________________________________________________________________________________

Birth history: relevant details

_______________________________________________________________
(Please check)
Has your child… Yes / No Description
Had any accidents/ injuries / serious illnesses in the past Yes / No
Has hearing been checked? Yes / No
Has vision been checked? Yes / No

As your child was growing up, were you concerned about… Yes / No
The first year? (e.g. hard to settle, poor weight gain?) Yes / No
Early motor development (sitting, walking, running, kicking)? Yes / No
Early language (talking and understanding)? Yes / No
Early social development (eye contact, play, friends)? Yes / No
Early learning (e.g. colours, shapes, drawing)? Yes / No
Primary School years - social relationships Yes / No
Primary School years – learning Yes / No
Primary School years – communication Yes / No
Primary School years – emotional changes/ mood Yes / No
Other Please describe: ________________________

_______________________________________________________________________________________________________
Family Members
Does anybody in the family (siblings, parents, grandparents, Yes / No
aunts, etc.) have problems similar to, or the same as your child?

Does anybody in the family (siblings, parents, grandparents, Ye / No

aunts, uncles etc.) have different problems, of a developmental
learning, behavioural, emotional or psychiatric nature?

Are there any other psychological, developmental or family issues that may be influencing your child’s difficulties?
____________________________________________________________________________________
____________________________________________________________________________________
Condition Relationship to Child Condition Relationship to Child

Alcoholism Nervous/psychological
Cancer Diabetes
Depression Suicide attempt
Heart trouble Other

Who have you previously consulted for your child’s difficulties?

(Remember to bring a copy of all written reports.)
1____________________________________________________________________________________________________
2____________________________________________________________________________________________________
3____________________________________________________________________________________________________
Important
Is there sensitive information you would prefer not to talk about in front of your child?
Yes No
If yes, we can discuss these issues while your child waits outside.
You may wish to bring a book or something they like to do while they wait.

If you feel that your child cannot wait or you need more time to discuss your child, come
to your initial appointment alone so you have the time you need. You can then discuss
bringing your child for the following appointment with your clinician.
* Please note your child must be in attendance to claim a Medicare Rebate under their Mental Health Care Plan.
Clinic: Shop 2, 33 Lisson Grove Wooloowin, 4030 (07) 3262-6009
reception@allaboutkids.com.au www.allaboutkids.com.au
Clinic: 6 A Mecklem Street, Strathpine, 4500 (07) 3132-3085
 3 of 8

Parent/Guardian Consent Form

Childs Name:_________________ Childs Date Of Birth:________________

Privacy Information: At All About Kids (AAK) we only collect information about your child
for the purposes of providing appropriate services to your child. We will not share the
information with anyone without your knowledge or consent.

Your signature (in the designated location below) indicates that you fully understand and
hereby grant permission to AAK practitioners to (tick all that apply):

o contact relevant professionals such as school/kindy staff and other health professionals
such as my child’s GP or other medical specialist if required, as part of the information
sharing process to assist with the allied health services offered through AAK. This may
also include another practitioner at AAK.
o correspond with myself and relevant professionals via email and phone regarding my
child when appropriate.
o correspond with my child’s other parent/guardian _______________ via email or phone
regarding my child when appropriate.
o photographic, audio or video material of my child to be collected during clinical sessions
to assist in their assessment or treatment.
o contact the following professionals and other agencies below if required, as part of the
data and information gathering process to assist with the allied health services offered
through AAK.

Please fill in each of the boxes below if relevant.

Organisation Organisation Name/Practice Contact Details e.g. Parents/
Contact Person Guardian
/Specialist Name/School Name Phone Number or Email Initials

GP

Medical Specialist
e.g. Paediatrician

School/Childcare

Allied Health
Professional

Other:__________

________________

All About Kids can contact and leave messages for me on the phone numbers provided below:

1____________________2____________________

All About Kids can email communications to me on ____________________ or _________________

- including new services offered, helpful newsletters and feedback surveys: Yes No

Parent/Guardian Name: ________________________

Clinic: Shop 2, 33 Lisson Grove Wooloowin, 4030 (07) 3262-6009

reception@allaboutkids.com.au www.allaboutkids.com.au
Clinic: 6 A Mecklem Street, Strathpine, 4500 (07) 3132-3085
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p 4-10
Strengths and Difficulties Questionnaire

For each item, please mark the box for Not True, Somewhat True or Certainly True. It would help us if you answered all items as
best you can even if you are not absolutely certain. Please give your answers on the basis of your child's behaviour over the last
six months.

Not Somewhat Certainly

True True True
Considerate of other people's feelings
D D D
Restless, overactive, cannot stay still for long
D D D
Often complains of headaches, stomach-aches or sickness D D D
Shares readily with other children, for example toys, treats, pencils
D D D
Often loses temper D D D
Rather solitary, prefers to play alone D D D
Generally well behaved, usually does what adults request D D D
Many worries or often seems worried D D D
Helpful if someone is hurt, upset or feeling ill
D D D
Constantly fidgeting or squirming D D D
Has at least one good friend D D D
Often fights with other children or bullies them
D D D
Often unhappy, depressed or tearful D D D
Generally liked by other children D D D
Easily distracted, concentration wanders
D D D
Nervous or clingy in new situations, easily loses confidence D D D
Kind to younger children
D D D
Often lies or cheats D D D
Picked on or bullied by other children D D D
Often volunteers to help others (parents, teachers, other children) D D D
Thinks things out before acting
D D D
Steals from home, school or elsewhere D D D
Gets along better with adults than with other children D D D
Many fears, easily scared D D D
Good attention span, sees chores or homework through to the end D D D
Do you have any other comments or concerns?
 5 of 8

Overall, do you think that your child has difficulties in one or more of the following areas:
emotions, concentration, behaviour or being able to get on with other people?
Yes- Yes- Yes-
minor definite severe
No difficulties difficulties difficulties
D D D D

If you have answered "Yes", please answer the following questions about these difficulties:

• How long have these difficulties been present?

Less than 1-5 6-12 Over
a month months months a year

D D D D

• Do the difficulties upset or distress your child?

Not Only a Quite A great
at all little a lot deal
D D D D

• Do the difficulties interfere with your child's everyday life in the following areas?
Not Only a Quite A great
at all little a lot deal
HOME LIFE D D D D
FRIENDSHIPS D D D D
CLASSROOM LEARNING D D D D
LEISURE ACTIVITIES D D D D
• Do the difficulties put a burden on you or the family as a whole?

Not Only a Quite A great

at all little a lot deal
D D D D

Mother/Father/Other (please specify:)___________________________

© Robert Goodman, 2005

 Payment & Cancellation Policy

If you need to cancel or postpone your appointment, please provide All About Kids Australia Pty Ltd with
at least one working days’ notice, otherwise you will be charged the full cost of the session. A working day
is defined as Monday to Friday 8am to 5pm and Saturday 8am to 12pm.

From 1st June 2016, cancellation fees will be calculated as follows:

1. For appointments cancelled more than one working day prior to the appointment No Charge
2. For appointments cancelled less than one working day prior to the appointment Full Fee
3. Non-attendance without notice Full Fee

We recognise that there are exceptional circumstances where this fee may not apply.
All About Kids Australia Pty Ltd reserves the right to waitlist future bookings when clients have had two or
more cancellations with less than one working day/s notice.
NOTE: The cancellation fee cannot be claimed through Medicare, HCWA or Better Start Package funding.
Fee Payment
If payment is not made on the day of an appointment, or if a cancellation fee is owing, an invoice will be
emailed to you. The appointment fee or cancellation fee will be charged to the credit card detailed in the
Credit Card Authorisation below and a paid invoice will be emailed to you for your records. All outstanding
fees must be paid prior to the provision of further services from All About Kids Australia Pty Ltd.

Late Attendance To Appointments Policy

We understand that there are times when children and families arrive late for appointments. In order to
respect clients with subsequent appointments in the day, your appointment must finish on time, and the
full appointment fee will still be charged.

Credit Card Authorisation

The following credit card will be kept on file and will be charged to cover outstanding fees as described in
the above fee payment policy. Credit Cards will be kept confidential on our secure practice system. An
invoice will be issued after this card has been charged.
Please fill in the following details:
Credit Card: ____ ____ ____ ____
Expiry: _ _/_ _ CVV (3 digit code on back of card): _ _ _
Name on Card: _________________________________
Policies Agreement
I, hereby agree that I have read and understood the Policies set out in this document by All About Kids
Australia Pty Ltd.
Client Name: _________________________________
Name (Person responsible for appointments and payment): _________________________________
Date: _________________________________

I understand that checking this box constitutes a legal signature confirming that I
acknowledge and agree to the above Policies Agreement.

Policy Amended: 1/11/2016

 7 of 8

Client Policies & Parent Consent

Confidentiality Policies

Psychologists within our clinic are bound by the APS Code of Ethics regarding Confidentiality (Section A.5.2),
as adopted by the Psychology Board of Australia. This states that client confidentiality must be maintained
with the specific exceptions related to duty of care and legal obligation. As APS members, this clinic also
abides by the Australian Psychological Society’s Ethical Guidelines “Guidelines for working with young
people”. This means that psychological therapy remains confidential unless permission is granted by the
client to discuss information disclosed during therapy sessions.
Confidentiality between a young person and their treating clinician is essential in order for treatment to be
successful. The clinician will always encourage the young person to talk with their parent but confidentiality
will only be breached when safety is a risk. Parental consent is required for assessments, therapy and other
information to be provided to a paediatrician, speech or occupational therapist, teacher or guidance officer.
Information pertaining to diagnosis and treatment suggestions will be provided to the referring
GP/Paediatrician.
All personal information gathered by the psychologist during the provision of the psychological service will
remain confidential and secure except where:
1. It is subpoenaed by a court; or
2. Failure to disclose the information would place you or another person at serious and imminent risk;
or
3. Your prior approval has been obtained to:
I. Provide a written report to another professional or agency, e.g. GP or lawyer; or

II. Discuss the material with another person, e.g. parent or employer or if disclosure is
otherwise required or authorized by law.

Practice Policy
All About Kids is a counselling and therapeutic intervention clinic. Clinicians conduct clinical, educational
and developmental assessments and provide intervention accordingly. All About Kids clinicians are able to
provide assessment and therapy reports as requested by clients for a range of requirements, including
providing information to schools, medical practitioners, parents and other therapists. Clinicians are also
available for teleconferencing or school visits in order to share or discuss pertinent information and
intervention strategies. An appropriate fee may be charged for the provision of such services.
The clinic does not routinely conduct family assessments or provide court reports for the Family Court of
Australia or other family dispute matters. The clinicians within the practice are not registered court
reporters. We do however have a number of psychologists to whom we refer our clients for such
assessments and reports.

Initial: __________

Clinic: Shop 2, 33 Lisson Grove Wooloowin, 4030 (07) 3262-6009

reception@allaboutkids.com.au www.allaboutkids.com.au
Clinic: 6 A Mecklem Street, Strathpine, 4500 (07) 3132-3085
 8 of 8

Parent/ Guardian Consent

Do you have a ‘Parenting Agreement” in place? YES NO

If yes, have you provided a copy to your psychologist? YES NO

1. I give permission for information regarding my child _________________________ be shared

with________________________________(Parent). YES NO

2. I give permission for information shared between myself and my child’s psychologist to be

disclosed to ________________________________(Parent) upon their request. YES NO

3. Are there any other legal lodgements your psychologist should know about that are relevant to
the child / children? i.e. A. V. O.

If yes, please provide details:

Forms and Policies Agreement

I understand that signing in the designated area below confirms that I have completed, read and
understood the forms and policies in this document. The information I have provided is correct and I agree
to the permissions and cancellation policies as part of the service provided by All About Kids.

Client's Name:
Guardian First and Last Name:
Date:

*Signature: __________________________________

*If you are unable to provide a digital signature please print this document out and sign it and email
it back or sign it and hand it to reception when you arrive for your appointment.

Clinic: Shop 2, 33 Lisson Grove Wooloowin, 4030 (07) 3262-6009

reception@allaboutkids.com.au www.allaboutkids.com.au
Clinic: 6 A Mecklem Street, Strathpine, 4500 (07) 3132-3085