Foundation Skills Group Referral Form

Client Information

Client First Name *

Client Last Name *

Date of Birth *

Address *

Suburb *

Funding Details

Funding stream *

NDISFee for Service (out of pocket)

NDIS Number

NDIS Plan (Please attach) You can access a copy of your NDIS Plan by logging into your MyGov account and clicking on the National Disability Insurance Scheme icon: https://my.gov.au/

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Diagnosis and/or medical conditions or allergies (please detail):

Referral Information

Parent/Caregiver First Name *

Parent/Caregiver Last Name *

Relationship to client *

Email Address *

Phone Number *

1. Has your child received any therapy services previously? (Please select all that apply) *

Speech PathologyOccupational Therapy PsychologyBehaviour SupportPhysiotherapySocial WorkSupport WorkOther

If 'other', please specify:

2. Does your child attend any other group environment? (Please select all that apply) *

ChildcareKindergartenSchoolOther

If 'other', please specify:

3. I'd like my child to attend (Please select all that apply): *

1 Day2 Days3 Days4 Days5 Days

4. My preferred days are (Please select all that apply): *

MondayTuesdayWednesdayThursdayFriday

Referral Details

1. Communication

How is your child currently communicating? *

Visuals or Augmentative and Alternative Communication (AAC) (e.g., visuals, communication book, speech output device).Non-speakingGestures (e.g., leading you by the hand)Echolalia (i.e., repetition of words, phrases, sentences your child has heard)Single words (e.g., help)Phrases (e.g., help me)Sentences (e.g., I need help)Conversations (i.e., back and forth talking about a topic with another person)

Additional information

If your child uses AAC, please detail which system they use:

What does your child communicate about? *

Wants and needsLikes and interestsPast events Unsure

Additional information

2. Play

How does your child like to play? *

Play by themselvesPlay alongside a peer or adultPlay with an adultPlay with other children

Additional information

3. Social

Does your child require support to: *

No concernsTake turnsShareInteract with peers

Additional information

4. Toileting

Does your child require support with toileting? *

YesNo

What does your child currently wear? *

UnderwearPull ups/nappyOther

If 'other', please specify:

Please select what level of support your child requires to complete of the toileting steps listed below: *

No support required, full independenceSome support required, visual (e.g., pointing, visuals, modelling) or verbal (telling them what to do) Physical support required (physically helping them do it or doing it for them)Not applicable

1. Knowing when they need to use the toilet (for wees)

No support required, full independenceSome support required, visual (e.g., pointing, visuals, modelling) or verbal (telling them what to do) Physical support required (physically helping them do it or doing it for them)Not applicable

2. Knowing when they need to use the toilet (for poos)

No support required, full independenceSome support required, visual (e.g., pointing, visuals, modelling) or verbal (telling them what to do) Physical support required (physically helping them do it or doing it for them)Not applicable

3. Knowing when they have wet themselves

No support required, full independenceSome support required, visual (e.g., pointing, visuals, modelling) or verbal (telling them what to do) Physical support required (physically helping them do it or doing it for them)Not applicable

4. Knowing when they have soiled themselves

No support required, full independenceSome support required, visual (e.g., pointing, visuals, modelling) or verbal (telling them what to do) Physical support required (physically helping them do it or doing it for them)Not applicable

5. Transitioning themselves to the toilet

No support required, full independenceSome support required, visual (e.g., pointing, visuals, modelling) or verbal (telling them what to do) Physical support required (physically helping them do it or doing it for them)Not applicable

6. Pulling down their pants

No support required, full independenceSome support required, visual (e.g., pointing, visuals, modelling) or verbal (telling them what to do) Physical support required (physically helping them do it or doing it for them)Not applicable

7. Sitting on (or standing in front of) the toilet

No support required, full independenceSome support required, visual (e.g., pointing, visuals, modelling) or verbal (telling them what to do) Physical support required (physically helping them do it or doing it for them)Not applicable

8. Doing a wee in the toilet

No support required, full independenceSome support required, visual (e.g., pointing, visuals, modelling) or verbal (telling them what to do) Physical support required (physically helping them do it or doing it for them)Not applicable

9. Doing a poo in the toilet

No support required, full independenceSome support required, visual (e.g., pointing, visuals, modelling) or verbal (telling them what to do) Physical support required (physically helping them do it or doing it for them)Not applicable

10. Wiping themselves

No support required, full independenceSome support required, visual (e.g., pointing, visuals, modelling) or verbal (telling them what to do) Physical support required (physically helping them do it or doing it for them)Not applicable

11. Pulling up their pants

No support required, full independenceSome support required, visual (e.g., pointing, visuals, modelling) or verbal (telling them what to do) Physical support required (physically helping them do it or doing it for them)Not applicable

12. Flushing the toilet

No support required, full independenceSome support required, visual (e.g., pointing, visuals, modelling) or verbal (telling them what to do) Physical support required (physically helping them do it or doing it for them)Not applicable

13. Washing hands

No support required, full independenceSome support required, visual (e.g., pointing, visuals, modelling) or verbal (telling them what to do) Physical support required (physically helping them do it or doing it for them)Not applicable

Does your child currently use any additional supports for their toileting at home? *

Foot stoolChild sized seatVisual scheduleVisual timerOther

If 'other', please specify:

Does your child have a continence care plan? *

NoYes

Please attach plan:

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Any other important information regarding your child’s toileting:

5. Sensory

Does your child display any of the below? (Please select all that apply) *

No concernsBecomes upset or appears uncomfortable (e.g., covering ears) when there is noise around themEnjoys making noise or soundsBecomes upset or appears uncomfortable (e.g., covering or closing eyes) when there is a lot of movement around them, bright colours and/or lightIs bothered by touch from other people, objects or texturesEnjoys touching items, people and/or engaging in messy playEnjoys and seeks out opportunities to engage in movement activitiesSeeks opportunities to put food and/or objects in mouth

Additional information

6. Gross motor

My child requires support with: *

No concernsMobility skills (e.g., walking, running, jumping, hopping, climbing, balancing, etc.)Ball skills (e.g., throwing, catching, bouncing, etc.)Sitting upright on a chair or on the floorOther

If 'other', please specify:

7. Fine motor

My child requires support with: *

No concernsManipulating items with their hands (e.g., stacking blocks, attaching and detaching Lego, rolling playdough)Handwriting and drawingSelf-feeding (i.e., using their hands the eat and cutlery skills)Opening and closing containersDressing and fastener skills (e.g., buttons and zips)Other

If 'other', please specify:

8. Mealtime

Do you have any mealtime concerns for your child? *

NoYes

If 'yes', please specify:

Has your child previously had a mealtime assessment or mealtime therapy? *

NoYes (please attach a copy of relevant reports)Currently on waitlist for mealtime assessment or therapy

Please attach mealtime reports:

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Does your child currently have an Oral Eating and Drinking Care Plan (OEDCP)? *

NoYes

If yes, please attach copy of plan.

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9. Emotion regulation

Does your child require support to: *

No concernsUnderstand and identify their own emotionsRegulate their own emotionsCope with change and transitionsEngage in non-preferred activitiesOther

If 'other', please specify:

10. Behaviour

Does the individual frequently display any of the below? Select all that apply (Please note this is to allow us to best identify appropriate supports and allocate within FSG) *

No concernsPinching/scratchingKickingBitingAbsconding (leaving a designated area)Hitting self Hitting othersProperty damageOther

If 'other', please specify:

11. Other

Please let us know if there are any other areas that you would like support for your child:

Thank you for completing this referral form to support in the allocation of Foundation Skills Group. Please click submit.

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