[Patient First Name]
Phone consult completed with Mother.
CLIENT INFORMATION
**Client Name:**
[Insert full name of client as recorded in transcript or clinical notes] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as concise sentence.)
**Date of Birth / Age:**
[Insert full date of birth and/or age as stated] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as concise sentence.)
**Legal Guardian:**
[Insert name and relationship of legal guardian] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as concise sentence.)
**Personal Information**
Living with:
[Describe household composition, including family members the child resides with] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as dot point or brief sentence.)
Siblings:
[Include information on number and age/gender of siblings if discussed] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as dot point or brief sentence.)
Family history:
[Summarise any relevant family history (medical, developmental, mental health, etc.)] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as dot point.)
School / Grade:
[State current school and grade] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as concise sentence.)
Languages spoken:
[List all languages spoken in the home or by the child] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as dot point.)
Likes/Dislikes:
[Summarise key likes or dislikes related to activities, environments, objects, etc.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as dot points.)
Allied Health Support:
[Document other allied health services currently accessed, including disciplines and frequency] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as dot points.)
Has seen an OT before? What goals were worked on?:
[Indicate if child has received OT previously and outline past focus areas] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as concise sentence or dot points.)
Main concerns reported:
[Summarise the primary concerns raised by parent/carer regarding the child] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write in concise sentences.)
MEDICAL HISTORY
**Pregnancy/Birth:**
Pregnancy Duration:
[Note length of pregnancy in weeks] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as brief sentence.)
Maternal Health:
[Describe any health concerns or complications during pregnancy] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as concise sentence.)
Birth Type:
[State delivery method] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as brief sentence.)
Birth Health:
[Note any complications, NICU stay, or initial concerns at birth] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as dot point or concise sentence.)
**Medical Conditions / Diagnoses:**
[List all medical conditions or formal diagnoses] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as dot points.)
**Health History:**
Hospitalisations:
[Note any admissions and reasons] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as dot points.)
Significant Illnesses:
[Summarise major illnesses that have impacted development or health] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as dot points.)
Epilepsy:
[Note if epilepsy is diagnosed or suspected] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as concise sentence.)
Surgeries:
[List any surgical procedures undertaken] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as dot points.)
Orthodontic Treatments:
[Summarise any current or past treatments] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as dot point.)
Tooth Removal:
[State whether teeth have been removed and under what circumstances] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as concise sentence.)
**Allergies:**
[Document any known allergies, including food, medications, or environmental] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as dot points.)
**Medications:**
[List current medications and purpose if known] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as dot points.)
**Hearing / Vision:**
Hearing Health:
[Summarise any hearing concerns or known issues] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as concise sentence.)
Last Hearing Ax:
[State date or recency of most recent hearing assessment] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as concise sentence.)
Vision Health:
[Note any vision-related diagnoses or use of glasses] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as concise sentence.)
Last Vision Ax:
[State date or recency of last vision assessment] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as concise sentence.)
SCHOOL / CHILDCARE SUPPORTS
**School:**
Name:
[Insert full name of school] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as concise sentence.)
Grade:
[Insert current school grade] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as concise sentence.)
Commencement:
[Note when child commenced at current school] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as concise sentence.)
Attendance Frequency:
[Summarise attendance pattern (e.g. full-time, part-time)] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as concise sentence.)
**Supports:**
[Outline any learning or behavioural supports at school] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as dot points.)
**Grades:**
[Note any academic strengths or concerns reported] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as dot points.)
**Enjoyment:**
[Describe child’s enjoyment or attitude toward school] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as concise sentence.)
**Other:**
[Capture any additional relevant school information] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as dot point or sentence.)
DEVELOPMENT HISTORY
**Communication:**
Babbling:
[State timing or concerns about babbling milestones] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as concise sentence.)
First Word:
[Document age or timing of first word spoken] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as concise sentence.)
Speech/language/communication concern:
[Summarise concerns regarding expressive, receptive language or speech sounds] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as dot point or sentence.)
**Motor:**
Tummy Time:
Rolling:
Belly Crawl:
Crawl:
Standing:
Walking:
[For each milestone above, note age achieved or any concerns if discussed] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write each as concise sentence.)
**Feeding:**
(See below.)
CURRENT FUNCTIONAL CAPACITY
**Self Care:**
[describe current level of independence, supports required, or concerns] (For each item below, describe current level of independence, supports required, or concerns. Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write each as concise sentence:)
Toileting:
Showering:
Dressing:
Feeding:
Brushing Hair:
Brushing Teeth:
**Eating:**
[Document behaviours, preferences, or difficulties with eating or mealtimes] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as concise sentences.)
**Play / Social Interaction:**
[Summarise child’s engagement in play, social interaction, and peer relationships] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as concise sentences.)
**Fine Motor:**
[Describe fine motor skills, strengths or difficulties with tasks requiring hand coordination] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as concise sentences.)
**Gross Motor:**
[Describe balance, coordination, endurance or difficulties with larger movement tasks] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as concise sentences.)
**Emotional Regulation:**
[Summarise self-regulation, frustration tolerance, meltdowns, emotional triggers etc.] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as concise sentences.)
**Sleep:**
[For each item below, document relevant details and concerns] (For each item above, document relevant details and concerns. Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write each as concise sentence:)
Bedtime:
Sleep Onset:
Sleep Duration:
Night Waking:
Enuresis:
Sleep Quality:
Snoring:
Mouth Breathing:
Sleep Walking/Talking:
Thumb Sucking/Dummy Use:
Day Naps:
**Sensory Processing:**
[Summarise any sensory sensitivities, seeking behaviours, or modulation difficulties] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as dot points.)
CURRENT NDIS PLAN DATES & GOALS (if applicable)
**Dates**
From:
[Insert start date of current NDIS plan] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely.)
To:
[Insert end date of current NDIS plan] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely.)
**Goals:**
[Insert goals from NDIS Plan verbatim] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Use direct quotes only.)
OPEN TO HOLIDAY INTENSIVE THERAPY BLOCK (if applicable)
Yes/No:
[Indicate response if parent explicitly confirmed openness to holiday block] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely.)
RECOMMENDATIONS:
[Include any therapist recommendations provided in consultation] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as dot points or short sentences.)
PLAN:
[Document proposed therapy frequency, focus areas or referral suggestions] (Only include if explicitly mentioned in transcript, contextual note or clinical note; else omit section entirely. Write as dot points or short sentences.)
ADMINISTRATIVE TASKS
Inform admin if additional weeks are required before completing your initial summary report (2-week buffer currently in place).
Inform admin if ongoing therapy appointments require removal — they are booked unless stated otherwise.
