New Patient - Child

Personal Details

Whether you have self-referred to our clinic; or have been referred by a Health Professional - we know it can be overwhelming for some.

_____________________

By taking the time to complete this form we hope to provide you with a streamlined assessment process that can improve the service we can provide; and aid in understanding your and your families needs.

If you don't understand any questions - please just answer to the best of your ability and we can clarify and review at your appointment.

Full name - Person completing this form *

Relationship to Child *

Personal Information - Child (person attending for assessment)

Prefix - other

Pronouns *

He / HisShe / HersThey / Theirs

First Name *

Last Name *

Date of Birth *

Current Age *

Gender *

Birth Sex *

Preferred Pronouns

Medicare Card Number *

Individual Reference Number (IRN) *

Expiry *

Private Health Cover *

Yes - Hospital and ExtrasYes - Hospital OnlyYes - Extras OnlyNo

Private Health Cover - DetailsPrivate Insurer Name, Membership Number and Expiry

Indigenous Identity *

AustralianIndigenous Australian - AboriginalIndigenous Australian - Torres Strait IslanderIndigenous Australian - Aboriginal and Torres Strait IslanderOther Ethnicity

Indigenous Identity - Other

School (or Kindy)

Current Year Level *

Teacher (this year / knows child best)

Teacher email

Siblings? *

YesNo

Siblings - Name and detailsList any siblings - Name, age and birth order - eg. 1) Older brother, Zach, 10 years 2) Younger sister, Kate, 6 years

Personal Information - Parent(s)

Family units are all unique - we respect and celebrate varied family structures!

Understanding your family helps us understand the important relationships in the child's life

Parent 1

Parent 2

First Name (Parent 1) *

First Name (Parent 2)

Last Name (Parent 1) *

Last Name (Parent 2)

Prefix - Other

Gender - Parent 1

Gender - Parent 2

Relationship to Child - other *

Relationship to Child - other

Email Address *

Email Address

Phone Number *

Phone Number

Are there any Court Orders in place?Please outline any specific custody arrangements and/or Court Orders regarding care

Family Setup if you have a non-traditional family

Do both parents listed above live at the same address? *

YesNo

Home Address *

Street address *

City *

State *

Postcode *

Home Address (Parent 2)

Street address

City

State

Postcode

Next of Kin - is this you? (Parent 1) *

YesNo

Next of Kin - Full Name *

Contact Phone *

Date of Birth (Parent) ** needed for Medicare Claiming for any children <17 years

Medicare Card Number (Parent) *

IRN: (Individual Reference No.) *

Expiry *

Relationship to child *

Other

Emergency Contact

Emergency Contact - Full Name *

Emergency Contact - Phone *

Consent

Heidi AI Scribe - Consent

YES - I Consent to use of Heidi AI to be used

Heidi AI is a Scribe AI tool that can allow your clinican to focus on you rather than a computer screen during your consultation.
Your consent to the use of this is essential - and your consent can be removed at any time.
Please ask our receptionists if you would like to review the comprehensive information sheet, including QR code for further, detailed information regarding Heidi AI Scribe's data / information / storage and compliance.
Heidi only uses Australian based Servers, No personal data is shared or stored with their servers.
Do you consent to your clinican using a Scribe-AI tool

NO - I do not consent to the use of Heidi AI for consultations.

Please be advised that due to the complexity of Kaleidoscope Clinic consultations (comprehensive mental health assessments) additional time and/or costs may result where this is unable to be utilised.

Consent to how we contact you *

YesNo

Do you consent to SMS (Messaging) or Email of results from our clinic, this includes recalls for the followup of results?

YesNo

Do you consent to receiving SMS (Messages) reminders of appointment(s)?

YesNo

If you need to reschedule an appointment please allow 24 hrs notice to allow another patient to access our services - failure to do may result in a late-notice cancellation fee. Cancellation fees are at the discretion of the provider and may be up to the full consult fee. Do you acknowledge this?

YesNo

Do you consent to the checking of your Medicare eligibility - this is important for certain services (eg. Mental Health Care Plan Item Numbers) - as we will endeavour to provide you access to Medicare funded services that may help with reducing out of pocket expenses.

YesNo

Consent regarding SMS/Messaging - If you do not consent to receive SMS appointment reminders you acknowledge that missed appointments will attract a full out of pocket fee for that appointment time.

Medical, Social and Family History

Medical Information

What is the primary reason for coming today? What do you want help with for your child? *

Other

Name of Referring Practitioner / Person

Why now? What has triggered this referral or assessment? *

?Childhood ADHDKnown ADHD diagnosis already from Paediatrician or Other Pratitioner- seeking continuation of treatmentSibling or Family relative with ADHD - with recognition of symptoms now in this childMental Health deterioration - eg. drop in mood, increased anxietyBehavioural concerns at school - eg. school refusal Substance use concern/issues - eg. alcohol, other drugsReferral from another health professionalConcerned about the possibility of ASD (autism or autistic traits), or this is an existing diagnosis

Choose all that apply

Childhod ADHD Diagnosis - who, your age, symptoms, treatments

Sibling diagnosed with ADHD - detailseg. Older brother had similar symptoms at same age. Diagnosed with ADHD, under Dr. Paediatrician. Poor tolerance to Ritalin but stable on Vyvanse

What behaviours are occurring; and how is this affecting the family? *

Substance use concerns

Mental Health Diagnoses - Details (date(s), who diagnosed condition, treatment recieved *

Eating Disorder History - Further Information *A lot of shame and guilt exists around disordered eating - whether that is restriction, purging or bingeing. They are often overlooked.

General Medical History (not Mental Health) *

Medications - List all current medications (including supplements) *

Allergies *

Social and Family History

Home and Family *Current living arrangements - who / any issues

Smoking and Vaping *

Smoking *

Alcohol *

Drugs other than alcohol and tobacco *

Family History (Medical and Mental Health) *Any significant Family History - eg. ADHD, Anxiety, Psychosis, Heart Disease

ADHD Specific

Parent / Guardian Declaration, Consent and Financial Agreement

I {{full name person completing this form}}, the {{relationship to child}} for {{first name}} {{last name}}

confirm that the information provided in this document, and any information provided verbally to clinicians at Kaleidoscope Clinic, has been completed honestly and to the best of my knowledge and ability.

I understand that accurate and complete information is important for safe and appropriate clinical assessment, diagnosis, and treatment planning. I acknowledge that incomplete or inaccurate information may affect the quality or appropriateness of care provided.

Acknowledge and Consent to Communication

Where relevant to patient care, I consent to Kaleidoscope Clinic clinicians communicating with appropriate professionals, which may include:

referring doctors or specialists
psychologists or allied health professionals
school wellbeing staff or teachers
relevant healthcare providers involved in care

This communication may include clinical summaries, reports, or recommendations necessary to support patient care.

Telehealth Consent (if applicable)

Where followup appointments are conducted via telehealth, I consent to the use of secure video or telephone consultation for clinical care.

I understand that:

telehealth consultations may have limitations compared with in-person assessments
privacy cannot be absolutely guaranteed in remote environments
the clinician may recommend face-to-face review where clinically necessary

Financial Consent

I acknowledge that Kaleidoscope Clinic is a private billing clinic.

I understand that:

consultation fees are payable in full at the end of the appointment unless otherwise arranged in advance
Medicare rebates may apply to eligible services and are typically processed after payment
any out-of-pocket gap fees remain the responsibility of the patient or parent/guardian

I accept financial responsibility for all consultation fees, assessments, report preparation, and other services provided for the patient.

Where written reports, letters, or documentation are requested or required, I understand that additional report preparation fees may apply depending on the time required.

I acknowledge that reports may take time to prepare following the consultation, particularly where comprehensive developmental or diagnostic assessments are involved.

Declaration from Parent / Guardian *

I have read and understood the information aboveI consent to the assessment process provided by Kaleidoscope ClinicI accept financial responsibility for fees associated with the services provided

Signature of Parent / Guardian *

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Date

Thankyou for taking the time to complete this information before your upcoming appointment.

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