Consent
Child’s Information
- Full Name: Emily Johnson
- Date of Birth: 15/04/2015
- Age: 8 years and 6 months
- Gender: Female
- NDIS Number: 123456789
- NDIS Plan Dates: 01/01/2023 - 31/12/2023
- NDIS Goals: Improve social skills, enhance fine motor skills, increase independence in daily activities
- Immediate Family: John Johnson (Father), Sarah Johnson (Mother), Michael Johnson (Brother)
Referral Information
- Reason for Referral: Concerns about delayed fine motor skills and social interaction difficulties
- Diagnoses
- Primary Diagnosis: Autism Spectrum Disorder
- Secondary Diagnosis: Sensory Processing Disorder
- Paediatrician: Dr. Lisa Carter, contact: 555-1234
- Family History of Diagnoses: No known family history of similar conditions
Medications
- Current Medications: None
- Medication Management: N/A
Family Factors/ Informal Supports
- Family Structure: Two-parent household with one sibling
- Home Environment: Spacious home with a dedicated play area
- Support Systems: Weekly occupational therapy, monthly family counseling
- Relevant Family Dynamics or Stressors: Recent move to a new city
- Current Living Environment: Detached house with backyard, both parents and one sibling reside
Formal Supports
- General Practitioner: Dr. Mark Lee, contact: 555-5678
- Paediatrician: Dr. Lisa Carter, contact: 555-1234
- Specialists: Dr. Anna Smith (Speech Therapist), contact: 555-8765
- Support Workers: Jane Doe, visits twice a week
- Speech Pathology: Weekly sessions focusing on communication skills
- Physiotherapy: N/A
- Psychology: Monthly sessions for emotional regulation
- Equine Therapy: N/A
- Music/ Art Therapy: Weekly art therapy sessions
Early Years / Developmental History
- Pregnancy and Birth:
- Full-Term: Yes
- Complications: None
- Developmental Milestones:
- Sitting Independently: 8 months
- Crawling: 10 months
- Walking: 15 months
- Talking (First Words): 18 months
- Noted Observations of Delays: Delayed speech and social interaction noticed at age 3
Activities of Daily Living (ADLs)
- Dressing:
- Can the child dress themselves independently? No
- Which types of clothing or fastenings are challenging? Buttons and zippers
- Bathing:
- Can the child bathe independently? No
- Are there specific tasks (e.g., washing, rinsing) they struggle with? Rinsing
- Toileting:
- Is the child toilet trained? Yes
- Do they need assistance with any aspects of toileting (e.g., wiping, handwashing)? Occasional assistance with wiping
- Grooming and Hygiene:
- Hair Brushing: No, requires assistance
- Teeth Brushing: Yes, with supervision
- Eating:
- Can the child use utensils and feed themselves independently? Yes
- Do they need help with meal preparation or eating (e.g., cutting food, handling utensils)? Assistance with cutting food
Sleep
- Sleep Hygiene/ Routine: Consistent bedtime routine, sleeps from 8 PM to 6:30 AM
- Bedtime/ Waking: Occasionally wakes during the night
- Sleep Quality: Generally good, with occasional disturbances
- Medication Compliance: N/A
Ability to Handle Changes in Plans and Routines
- Response to Changes: Becomes anxious with sudden changes
- Adaptability: Needs time to adjust to new situations
Instrumental Activities of Daily Living
- Household Chores:
- Can the child assist with household chores (e.g., setting the table, cleaning up)? Yes, with guidance
- Which chores can they complete independently? Setting the table
- Managing Personal Belongings:
- Can the child organise and manage their personal items (e.g., school supplies, clothing)? No, requires assistance
- Money Management:
- Is the child able to manage and use money (e.g., making purchases, understanding value)? No
- Do they need assistance with budgeting or handling money? Yes, requires full assistance
- Transportation:
- Can the child use public transportation or travel independently? No
- What kind of support do they need with transportation (e.g., navigating routes, safety)? Requires supervision and guidance
School Performance and Participation
- Performance and Engagement in the School Environment:
- Classroom Behavior and Functioning: Struggles with attention and following instructions
- Participation and Engagement: Engages with support, struggles with group activities
- Additional Supports: Receives one-on-one support in the classroom
Cognition and Communication
- Executive Functioning:
- Planning and Organization: Needs assistance with planning tasks
- Problem-Solving: Requires guidance
- Flexibility: Struggles with flexibility
- Inhibition/Impulse Control: Needs support to manage impulses
- Working Memory: Challenges with retaining information
- Attention:
- Sustained Attention: Limited attention span
- Selective Attention: Difficulty focusing on relevant tasks
- Divided Attention: Struggles with multitasking
- Memory:
- Short-Term Memory: Needs repetition to retain information
- Long-Term Memory: Generally good
- Episodic Memory: Can recall specific events with prompting
- Semantic Memory: Good understanding of facts
- Language and Communication:
- Receptive Language: Understands simple instructions
- Expressive Language: Limited vocabulary, uses gestures
- Comprehension: Needs support to understand complex language
Reasoning and Judgment
- Logical Reasoning: Needs support to draw conclusions
- Abstract Reasoning: Struggles with abstract concepts
- Judgment: Requires guidance in decision-making
Impressionability: Easily influenced by peers
Social and Community Participation
- Community Activities: Participates in weekly community playgroup
- Social Skills with Familiar People:
- Interaction with Family and Friends: Engages well with familiar people
- Social Skills with Unfamiliar People:
- Interaction with Strangers: Shy and reserved
- Community Support: Access to local support groups
Emotional Regulation/ Self-Regulation
- Emotional Responses: Becomes frustrated easily
- Self-Regulation Skills: Needs support to manage emotions
- Emotional Regulation Strategies: Uses deep breathing techniques
Behaviours of Concern
- Types of Behaviours: Occasional tantrums, repetitive behaviors
- Triggers and Patterns: Changes in routine, sensory overload
- Impact on Daily Functioning: Affects participation in group activities
- Coping and Management Strategies: Use of visual schedules, sensory breaks
- Response from Others: Supportive responses from family and educators
Revised NDIS GOALS: Enhance social interaction, improve fine motor skills, increase independence in daily tasks
Recommendations: Continue occupational therapy, introduce social skills group, explore additional sensory integration therapy
