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Baby Bridges Client Profile

Child's Name:: First Name:
Last Name:
Date of Birth:
Address:: Line 1:
Line 2:
City:
Country:
State:
Postal Code:
I was born in (country of birth):
My gender is:: MF
My diagnosis is:
I am registered with Disability Services:
I live at home with my family:
My family take care of me all the time:
Sometimes I will go and stay with friends who will care for me to give my family and myself a break:
: My nominated contact person's details
Name:: First Name:
Last Name:
Mobile Number:
Email Address:
My siblings name/s and age/s are:
I am currently or have previously consulted a Physiotherapist:
Start Date:
End Date:
Per period:: WeeklyFortnightlyMonthlyAnnuallyNot applicable
Frequency:
Length:: up to 30 minutes30 mins to 60 mins1 hr to 2 hrs2 hrs - half dayFull day
Physiotherapist's Name:
I am currently or have previously consulted a Speech Therapist:
Start Date:
End Date:
Per Period:: WeeklyFortnightlyMonthlyAnnuallyNot applicable
Frequency:
Speech Therapist's Name:
I am currently or have previously consulted a Occupational Therapist:
Start Date:
End Date:
Per Period:: WeeklyFortnightlyMonthlyAnnuallyNot applicable
Frequency:
Length:: up to 30 minutes30 mins to 60 mins1 hr to 2 hrs2 hrs - half dayFull day
Occupational Therapist's name:
I am currently or have previously consulted a Social Worker:
Start Date:
End Date:
Per Period:: WeeklyFortnightlyMonthlyAnnuallyNot applicable
Frequency:
Length:: up to 30 minutes30 mins to 60 mins1 hr to 2 hrs2 hrs - half dayFull day
Social Worker's Name:
I am currently or have previously consulted a Psychologist:
Start Date:
End Date:
Per Period:: WeeklyFortnightlyMonthlyAnnuallyNot applicable
Frequency:
Length:: up to 30 minutes30 mins to 60 mins1 hr to 2 hrs2 hrs - half dayFull day
Psychologist's Name:
I am currently or have previously seen Family & Early Childhood Services (FECS) Team:
Start Date:
End Date:
Per Period:: WeeklyFortnightlyMonthlyAnnuallyNot applicable
Frequency:
Length:: up to 30 minutes30 mins to 60 mins1 hr to 2 hrs2 hrs - half dayFull day
Please list 5 current goals you are working on for child:
My carer is receiving Carer Payments:
I am receiving disability funding:
Medical Aids Subsidy Scheme:: YesNo
Better Start Funding:: YesNo
Helping Children with Autism:: YesNo
To communicate effectively I need to use the following communication aids or signs:
To get your attention I will:
I have allergies:
I am allergic to:
Reaction:
Treatment:
I can drink out of a cup:
I can feed myself:
I have epilepsy:
The seizures that I have are called:
My seizures normally last for:
My usual seizure is like this:
When I am having a seizure can you please:
I have difficulty with my vision:
My condition is:
I need to wear glasses:
I have difficulty with my hearing:
I need to wear hearing aids:: YesNo
You can help me with my food by:
: Behaviour. This is a tricky one as some people say that I have behaviours but it is mostly because I want someone's attention.
When I do not get attention I become upset:
Some of these triggers are:
I'm not allowed to participate in these recreational activities:
Please check items you'd like further information on:: National Disability Insurance SchemeThat my child's needs will increase requiring more support & fundingHow to contact government departments and what is the processFunding applications - where do I start, and what do I doHow to plan for the future at any stageHow to meet the additional requirements for support and funding during critical periodsWho can provide advocacy for my child in the futureIntervention before future crisis occursCommunity Education eg acceptance of people with a disabilityManaging the effects of my caring role in order to achieve financial securityWho will look after my child in the event of my sickness or my passingMy child starting childcare / kindergartenMy child starting school
Other concerns:

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