PRIVATE & CONFIDENTIAL

To proceed with your child's telehealth medical appointment, please complete all required fields and submit the form. You can save your progress and return later if needed. Once the form is complete, please click 'Submit.'

This form is required before your appointment and will be securely stored in your patient records. If you have any questions or need assistance, please contact a Telecare Coordinator at 03 9052 4872.

Your Details

Relationship to the Patient *

Your name *

Mobile Phone *

Home Phone

Postcode *

Street Address

City/Suburb

State *

This is also my nominated postal address *

YesNo

Postal Address

Parent/Guardian Email *

Are the parents *

living togetherseparatedone surviving parent

Mother's Name *

Date of Birth (for Medicare Rebate purposes) *

Age

MOTHER's mobile phone *

Occupation *

FATHER's Name *

Father Occupation *

Guardian's Name *

Guardian's DOB (for Medicare purposes) *

Guardian's Age

Other guardian/s? *

YesNo

Full name

Mobile phone

Occupation

Siblings? *

YesNo

Sibling name

Sibling Age *

Additional Siblings?

YesNo

Next of Kin and/or Alternate Contact Person NAME *

Next of Kin and/or Alternate Contact's MOBILE NUMBER *

Family Doctor (If different from referring doctor)

YesNo

Medical History

Is Immunisation up to date? *

YesNo

Comments

Has the patient previously seen a paediatrican *

YesNo

Approximate Date of last appointment:

I consent for Telecare to obtain a copy of my child's report/s from our GP, hospital and/or pathology/radiology clinic, in preparation for the consultation *

Name and Date of diagnostic test *Please include the pathology/radiology/hospital where you had your test and estimate time (e.g. January 2023)

Relevant Medical Records

Browse

Medical report, school reports, diagnostic reports etc

Relevant Medical Records (additional)

Browse

Medical report, school reports, diagnostic reports etc

Any other relevant information you'd like your specialist to know

Preferred Local Pharmacy

Do you have a preferred local pharmacy for obtaining medications?

YesNo

Patient (CHILD'S) Details

Patient's First Name *

Patient's Last Name *

Date of Birth *

Sex assigned at birth *

Is the patient 17 years of age or younger *

YesNo

Knowing your cultural background can help us provide healthcare that meets your individual needs. Are you Aboriginal or Torres Strait Islander origin?

AboriginalTorres Strait IslanderAboriginal and Torres Strait IslanderNone of these

At which stage of Education is the patient? *

Pre-school (day-care)Primary SchoolSecondary SchoolPost-secondary

Specialty you have been referred to***IMPORTANT*** Please ensure you've selected the CORRECT Speciality as this will affect the rest of this form - if you're unsure, please speak with a Telecare Booking Coordinator phone 03-9052-4872

Is this appointment also for mental health support or diagnosis? *

Yes - Never been diagnosedYes - Previously been diagnosedNo

Medicare

Do you use a different name on your Medicare card?

YesNo

Please write the alternate name & surname printed on your Medicare card

Medicare First Name

Medicare Surname

Medicare Card No. *

Reference No.(This is the single digit number next to your name on the Medicare card)

Medicare - Expiry

Parent/Guardian Medicare Card No. *(Guardian details are required for patients 17yrs and under)

Parent/Guardian Ref No.(This is the single digit number next to your name on the Medicare card)

Guardian Card Expiry

Payment Details and Cancellation Policy

Prepayment:

By proceeding, you accept the medical consultation fees provided during the booking process. If you have any questions about fees or payment options, please contact Telecare at least 72 hours before your appointment. Telecare will securely collect your card details through Eway, an Australian-based payment platform. You may request to update or remove your details at any time by emailing admin9@telecare.com.au.

You agree that your payment method will have sufficient funds to cover the full fee and consent to Telecare using your stored card details for any follow-up consultations you book and attend. Payment will be processed 72 hours before your appointment.

If your payment is declined, a late payment administration fee may apply.

Cancellation/Missed Appointments:

Our specialists (and your GP, if applicable) have reserved time specifically for you. If you need to cancel your appointment, we kindly request 48 hours' notice so that we can accommodate another patient in need. Missed appointments or cancellations made without a valid medical reason within 48 hours of the appointment will incur a fee of $150.

Surcharge:

A credit card surcharge applies (1.7% + 20¢ per transaction). For bank transfer details, please contact our office. Electronic funds transfers must be received in Telecare’s account no later than 72 hours before your appointment.

If you receive an error and/or cannot lodge your form, please call Telecare ph 03-9052-4872 and speak to our team for assistance - We may SMS/call you if your form is not received by 72hrs prior to your appointment - *Without a complete form, your appointment may be cancelled*

Telepsychiatry and S8 Medication Prescription and Limitation

Most of our psychiatrists primarily offer assessment and diagnostic services under Medicare Item 291.

Following the appointment, our psychiatrists will provide your GP with a comprehensive report, which will include the assessment findings and a detailed management plan to support your ongoing care.

Please note that most of our psychiatrists do not prescribe medications directly. Instead, they will collaborate closely with your GP, who will handle any necessary prescriptions.

If you have been diagnosed with attention deficit hyperactivity disorder (ADHD), your psychiatrist may recommend medications such as Lisdexamfetamine (Vyvanse) or Methylphenidate (Ritalin), which are restricted drugs. Your GP can use the psychiatrist's report to apply for a permit to prescribe these medications. In many states, GPs can prescribe these medications if they have a letter from a psychiatrist and obtain the required authorization.

It is important to discuss this arrangement with your GP before your psychiatrist appointment, as some GPs may be unable to prescribe these medications, unable to apply for authorization, or may have limited capacity for ongoing prescribing.

Yes, I agree *

I understand that in most cases, telehealth psychiatry is not suitable for the provision of ongoing care. Further appointment/s to discuss and/or adjust a treatment plan will be reviewed upon GP request.
Ongoing counselling and mental health support may be available with a psychologyist or psychotherapist (please speak with your GP if you are eligible for a care plan) *

ADHD Medication Waiver

This informed consent and waiver is provided to you in relation to the prescription of psychostimulant medications. You must acknowledge and agree to the following terms before such medications may be part of a treatment plan.

Where this Form refers to 'we', 'us', 'our' as Telecare Australia, and also includes our personnel, including all practitioners on our website or portal.

Where the Patient is a minor, or is otherwise unable to complete this Form, the Authorised Representative set out in the table above may sign this Form on behalf of the Patient and, in such cases, you will mean the Authorised Representative. You warrant and agree that, if you are completing and signing this Form on behalf of the Patient, that you have the required authority to do so.

This informed consent and waiver shall remain in effect for the duration of the Patient's treatment with the prescribed psychostimulant medication, unless revoked or amended in writing by the Patient or Authorised Representative.

Prescription of the Medication

You agree to follow your treating medical practitioner’s instructions regarding the proper use, dosage, frequency, and duration of the prescribed psychostimulant medication. You understand that failure to comply with these instructions may result in adverse effects or diminished therapeutic benefits.

You confirm that you have read and understood the information provided to you regarding the prescribed psychostimulant medication, including the potential risks, benefits, and side effects associated with their use.

You understand that you have the right to withdraw your consent for the treatment with psychostimulant medication at any time. To do so, you must provide written notice to your treating medical practitioner, and you agree to follow any instructions provided by them regarding the safe discontinuation of the medication. In the event of an emergency, where you cannot contact your treating medical practitioner, you agree to seek appropriate medical advice from your nearest open medical clinic or emergency room.

Use of Recreational Drugs

You confirm that the Patient is not currently using any recreational drugs. You acknowledge and agree that using recreational drugs while taking prescribed psychostimulant medications can lead to adverse health consequences.

You acknowledge that you have had the risks associated with taking psychostimulant medications explained to you, including the potential for abuse, dependence, and other side effects.

You acknowledge and agree that it is your responsibility to ensure you do not use any recreational drugs while taking the prescribed psychostimulant medication.

Liability

To the maximum extent permitted by law, we (and our personnel, including any medical practioners) will not be liable for any harm or injuries the Patient may suffer as a result of not following recommendations regarding the use of psychostimulant medication, unless we are negligent.

Emergency Services

You acknowledge and agree that we may call emergency services if (at our sole discretion) we have the reasonable opinion that the Patient is putting themselves or a third party at risk of harm.
Telecare is not an emergency service. In the event of an emergency where you are unable to contact your treating medical practitioner, you will seek appropriate medical advice from the nearest open medical clinic or emergency room.

I acknowledge and agree that I have read, understood, and agree to the terms outlined in this waiver.

Signed by the patient or Signed for and on behalf of the Patient by their Authorised Representative who warrant that they have the proper authority to do so

Paediatric development and behavioral assessments

Thank you for choosing one of Telecare's paediatricians who specialise in development and behavioural assessments for your child. We want to make sure you understand what to expect during the assessment process.

Multi-Step Procedure: The assessment is a detailed process with several steps. It might take multiple appointments to fully evaluate your child's condition.
Review of Notes and Results: With consent from the parents/carers, our paediatricians will carefully review various notes and investigation results, like medical records, previous assessments, and relevant tests. This helps them understand your child's medical, developmental, and behavioural history. If you have any reports that may be relevant, please send them through before the appointment.
Collaboration with Others: To make an accurate diagnosis, our paediatricians work with other healthcare professionals, educators, and caregivers involved in your child's care. This collaboration provides a better understanding of your child's unique situation.

Please remember that a thorough assessment may take time and careful consideration. We appreciate your patience as we work towards the best outcome for your child. We aim to provide the best care and accurate diagnoses for your child's needs. If you have any questions or concerns, our team is here to support you.

Yes, I agree *

Yes, I agree. *

Consent to provide information

If you are actively suicidal and/or contemplating significant self-harm, Telecare’s virtual care model may not be sufficient for your needs. Please consider urgently speaking to your GP, contacting your local crisis mental health team or presenting to your nearest Emergency Department, we will return your care to your GP to support you with alternative local care in such case.

I agree, that on initial attendance of a telepsychiatric consultation with Telecare a screen shot may be taken, with your verbal agreement and knowledge , to capture your photographic image. This is required for :

Identification of the patient
Clinical documentation of presentation during the interview

The screenshot will be stored confidentially within your electronic medical record and handled in accordance with the Privacy Act 1988 (Cth).

Obtaining medical information

As part of providing a clinical service to you, Telecare's specialist or allied health provider will need to collect and record personal information from you that is relevant to your current situation. This information will be a necessary part of the assessment and treatment that is conducted.

Purpose of collecting and holding information

The information is gathered as part of the assessment and is seen only by your provider and Telecare staff. The information is retained to document what happens during sessions and enables the provider to provide a relevant and informed clinical service.

Access to Client Information

At any stage you as a client are entitled to access to the information about you kept on file unless the relevant legislation provides otherwise. The provider may discuss with you appropriate forms of access.

Confidentiality

All personal information gathered by the provider during the provision of the service will remain confidential and secure except where:

It is subpoenaed by a court, or
Failure to disclose the information would place you or another person at serious risk/danger/harm; or
To provide a written report to another professional or referring agency eg. a GP to discuss the material with another person, eg. a parent or if disclosure is otherwise required or authorised by law. It is a Medicare requirement that progress reports be sent to the referring GP.

Yes, I agree *

DEVELOPMENTAL HISTORY

PRIVATE & CONFIDENTIAL

Completed by one or both guardians of a patient

Please complete all required fields and submit your form at least 72 hours prior to the patient's appointment. This form will be provided to the patient's specialist doctor.

QUESTIONNAIRE

Pregnancy

1. How many pregnancies have you (mother) had? *

1. How many pregnancies has the mother of the subject had? *

2. Was this a planned pregnancy? *

YesNoUnsure

3. Did you (mother) have any health, including mental health, problems during the pregnancy? *

YesNo

3. Did the subject's mother have any health, including mental health, problems during the pregnancy? *

YesNoUnsure

4. Were you on any medication during this pregnancy? *

YesNo

4. Was the subject's mother on any medication during this pregnancy? *

YesNoUnsure

5. During pregnancy, did you (mother) drink alcohol? *

YesNo

5. During pregnancy, did the subject's mother drink alcohol? *

YesNoUnsure

6. During pregnancy, did you (mother) smoke cigarettes? *

YesNo

6. During pregnancy, did the subject's mother smoke cigarettes? *

YesNo

7. During pregnancy, did you (mother) use any illicit substances? *

YesNo

7. During pregnancy, did the subject's mother use any illicit substances? *

YesNoUnsure

Birth

8. Was s/he premature or born at full term? *

9. Type of delivery? *

10. Birth weight? *

11. Did he/she require any resuscitation at birth? *

YesNo

12. Did s/he need to go to Special Care Baby Unit? *

YesNo

13. How long were you in hospital for? *

Infancy / young child

15. What was s/he like as a baby? eg. settled, difficult to settle. *

16. Was s/he easy to get into a routine? *

YesNo

17. How did s/he sleep? *

18. How did you bond? Any postnatal depression? *

19. Did you breast or bottle feed? *

20. Did s/he make eye contact during feeding? *

YesNo

21. How old was s/he when weaned to solids? Any difficulties? *

22. Any feeding difficulties? *

YesNo

23. Did s/he like to be held? Could you comfort him/her? *

YesNo

24 Was s/he hard to keep busy? *

YesNo

25. Was he/she overactive? *

YesNo

26. Was s/he stubborn or challenging? *

YesNo

27. Did s/he show a normal wide range of emotions, or were they quite flat emotionally? *

28. Was s/he affectionate? Would s/he seek comfort? Would s/he try to comfort others if upset? *

YesNo

29. Was s/he sociable eg would point at things, look at what you were looking at, want to show you things they liked? *

YesNo

30. How did s/he let you know he/she wanted something before they could speak? *

31. Did s/he use non-verbal communication including pointing, eye contact? *

YesNo

32. Did s/he ever use your hands like a tool eg. to open something? *

YesNo

33. Did s/he ever imitate adults eg. pretend to brush their hair, sweep? *

YesNo

Milestones

34. How old was s/he when:

Crawled: *

Walked: *

Babbled: *

First word: *

Put two words together: *

Speak in sentences: *

Dry during the day: *

Dry at night: *

Day Care

35. Did s/he go to day care? At what age? *

YesNo

36. How did s/he cope separating from you? *

37. How did s/he interact with the other children? *

38. Did s/he play with other children or play beside them? *

39. Did day care staff have any concerns about your child? *

YesNo

Primary Education

⚠️ Questions in this field will be hidden as they are not applicable to the subject

40. What age was s/he when he went to primary school? *

41. How did s/he cope with the transition to primary school? *

42. How did s/he do academically at primary school? *

43. How did s/he interact with other children at primary school? Did he/she have friends? What was the quality of these friendships? *

44. Does s/he make friends easily? Or does s/he have difficulty keeping friends? *

45. Did the teachers raise any concerns at primary school? *

YesNo

Secondary Education

⚠️ Questions in this field will be hidden as they are not applicable to the subject

46. What age was s/he when he went to high school? *

47. How did s/he cope with the transition to high school? *

48. How did s/he do academically at high school? *

49. How did s/he interact with peers at high school? Did s/he have friends? What was the quality of these friendships? *

50. Have the teachers raised any concerns at high school? *

YesNo

51. Does s/he have/had a job? *

YesNo

52. How has s/he coped with having a job? *

53. Age when s/he left school? What has s/he done since? Any difficulties in these settings? *

Adolescents

⚠️ Questions in this field will be hidden as they are not applicable to the subject

⚠️ This question is only applicable to subjects over the age of 10 years old. Please select not applicable if the subject does not fit into this age range.

54. Does s/he understand humour? Sarcasm? *

YesNoNot applicable

55. Does s/he understand metaphors? *

YesNoNot applicable

For all questions below, please provide details about the nature of the difficulties

⚠️ Please answer the following questions to the best of your ability. Some questions may not be applicable; if so please select "Not applicable" or type "N/A" into the relevant text box.

R1. Thinking about his/her school work and about his/her ability to reason things out, is s/he about average for his/her age, ahead, or behind? *

AheadAverageBehindNot Applicable

R2. At present, roughly what sort of age level is s/he at in his/her school work and ability to reason things out? (Optional: For example like an average [insert an age 2 years younger than the child's chronological age] year old?) *

R3. Is his/her ability to use language - to say what s/he means and to understand what other people are saying - about average for his/her age, ahead or behind? *

AheadAverageBehind

R4. At present, roughly what sort of age level is s/he at in his/her use and understanding of language? (Optional: For example like an average [insert an age 2 years younger than the child's chronological age] year old?) *

R5, Can s/he get around difficulties in explaining what s/he wants to say by other means, for example by using gestures, signs, facial expressions or acting things out? *

NoA littleA lot

R7. Have the things that seriously worried you or someone else now cleared up completely? *

Cleared up completelySome continuing problemsThere were no worries

⚠️ Skip rule for the rest of this section!

Only continue if R7 = 'Some continuing problems', or if the SDQ peer problem score is 2 or morepoints higher than the prosocial score. Otherwise go to next section.

If you did not select "Some continuing problems' you will be unable to view questions R8 - R43

If R6a = 'Yes', please answer R8 and R9, otherwise skip to R10

R8. Could s/he use any real words other than 'mama' or 'dada' before the age of 2 years? (Baby words such as 'bickie' for 'biscuit' do count. Exclude other words for mother or father) *

NoYes

R9. After using single words, children go on to join them up into phrases or short sentences like 'Go park see ducks' or 'Mama give biscuits'. Did s/he join words together into phrases or short sentences before the age of 3 years? (Do not count set phrases like 'Thank you' or 'Night night' that the child uses as just one word) *

NoYes

R10. Toddlers often communicate through physical gestures such as waving goodbye, pointing to things, blowing a kiss, or bringing a finger to their mouth and saying Shh! Whens/he was a toddler, did [Name] use these sorts of gestures as much as other children of the same age? *

About the same/moreA little lessA lot less

R11. Some children like playing nursery games like Ring a Ring a Roses, Round and Round the Garden, Peekaboo. Did s/he ever like these games? *

NoA littleA lot

R12. Young children often try to share their enjoyment or interests or achievements, for example by pointing out something that they think you will enjoy seeing or find interesting. As a toddler and young child, did s/he want to share his/her enjoyment, interests or achievements with other people? *

NoA littleA lot

R13. Some children spend a lot of their play time repeating the same action over and over again, for example spinning the wheels on a toy car, turning taps or light switches on and off, or opening and shutting doors. Has this ever been true of him/her? *

NoA littleA lot

R14. Children are sometimes very interested in unusual aspects of toys or other things. For example, rather than playing with a toy, they may spend their time sniffing it, or running their fingers over its surface, or holding it to their face to feel any vibration that it makes. Has this ever been true of him/her? *

NoA little A lot

Make-believe play is important to some children. This can include pretend games with other children - games such as cops and robbers, or mummies and daddies. Even when they are by themselves, children may act out stories with dolls, action men or make-believe objects.

Is the subject under the age of 11? (This is required for R15 & R16) *

NoYes

R15. As a preschool child and more recently, has s/he taken part in make-believe play? *

NoA little A lot

R15. Thinking about when s/he was younger (say between 5 and 10), did s/he take part in make-believe play? *

NoA little A lot

R16. At present, can s/he make allowances according to who s/he is playing with? For example, not being too rough when playing with younger children, and not being too bossy when playing with older children. *

NoA little A lot

R16. Whens/he was younger (say around 10), could s/he make allowances according to who s/he was playing with? For example, not being too rough when playing with younger children, and not being too bossy when playing things with older children. *

NoA little A lot

R17. When s/he' s with other children/teenagers, does s/he have difficulty taking turns, sharing or co-operating? *

NoA little A lot

R18. Some children/teenagers enjoy putting a lot of time into collecting things, or get a lot of pleasure out of focusing on just one topic, such as sport, cars or a particular pop group. In everyday language, we often say that these children/teenagers are 'obsessed' by their interest, but this is not an unpleasant obsession - this is something they like and usually enjoy talking about. Has s/he had any long-lasting obsessions of this sort? *

NoA little A lot

R19. Obsessions may be about common or unusual topics. For example, it is fairly common for an 8 year old to be obsessed by dinosaurs, but it is unusual for an 8 year old to be obsessed by Victorian fireplaces, bar codes or street lamps. Is or was the topic of his/her obsession unusual? *

NoA little A lotNot Applicable

R20. Does or did the obsession dominate his/her life? *

NoA little A lotNot Applicable

R21. Does or did it tend to dominate his/her conversation with other people? *

NoA little A lotNot Applicable

R22. Does or did it stop him/her doing other important things in his/her life, such as playing, studying or going out? *

NoA little A lotNot Applicable

R23. Please describe the obsession *

R24. Is s/he able to start conversations with other people? *

NoA little A lot

R25. If other people start conversations with him/her, can s/he keep the conversation going? *

NoA little A lot

R26. Is s/he genuinely interested in chatting with other I peqple in order to hear what they have to say about their experiences and interests - even if those interests are different from his/her own interests? *

NoA little A lot

R27. Some children/teenagers have trouble adjusting their language to suit different social occasions. For example, they may speak too casually to a teacher or too formally to other children. Does s/he change the ways/he speaks according to whether it is a formal or informal situation? *

NoA little A lot

R28. It is relatively easy to tell what some children/teenagers aie feeling by observing their facial expressions, their tone of voice and their body language. It is harder to tell with other children/ teenagers, particularly if you don't know them very well. Do most people have difficulty knowing what s/he is feeling by observing his/her face, body language or tone of voice? Please describe. *

NoA little A lot

R29. The other way round, children/teenagers vary in their ability to know what other people are feeling. Some children/ teenagers are good at recognising subtle clues in body language, facial expressions, or tone of voice. For example, they can immediately tell when their mother is starting lo get a little cross, or when another child/teenager is feeling a bit embarrassed. Other children/teenagers find this much harder. Does s/he have difficulty recognising the clues in other people's facial expressions, body language and tone of voice? Please describe. *

NoA little A lot

R30. When we're talking with someone face-to-face, eye contact is very important. It generally makes us feel uneasy, or as if there's something wrong, if the other person makes too little eye contact, or too much, or makes it at the wrong time. Has s/he ever been through a phase of making too I I little or too much eye contact, or making it in the wrong sort of way? Please give examples. *

NoPerhapsDefinitely

R31. Many young children go through a phase of repeating what someone has just said to them. For example, if you said, "We'll be going home in a few minutes", they might parrot back "We'll be going home in a few minutes". Or they might echo back the last word, "minutes", in your tone of voice. Some young people do this a lot. Has s/he ever echoed or parroted speech in this way? Please give examples. *

NoA little A lot

R32. Some children/teenagers ask the same questions over and over again. For example, ''When are we going to the park?" or "What's for dinner?" or "Are we going swimming this weekend?" They keep repeating these questions even though they've already been told the answers many times. The questions that are repeated may not be exactly the same from week to week. Has s/he ever tended to ask repetitive questions? Please give examples. *

NoA little A lot

R33. Another way in which young people repeat themselves is by using the same catch-phrase or cliché over and over again. For example, almost every sentence may begin "If you want my opinion ... " or "Logically speaking..." Occasionally the phrase is appropriate, but it is used far more than is really needed. Has s/he ever filled his/her speech with these fairly empty catch-phrases or cliches? Please give examples. *

NoA little A lot

R34. Some children enjoy routines and want things to be the same every day. For example, they may want to eat the same food off the same plate while sitting in the same chair every single day. Or there may be very fixed routines for dressing or undressing. Has s/he ever had strong or unusual routines that s/he has insisted on because s/he enjoyed doing it that way? *

NoA little A lot

R35. Please describe these routines *

R36. Some children are easily upset by small changes in their routines. For example, they may be very upset by having to go to school a different way, by having to take a bath at a slightly different time, or by the furniture being moved around. Has s/he ever been easily upset by changes in routine? Please describe. *

NoA little A lot

R37. Some preschool children go through a phase of flapping or waving their hands or arms up and down if they are excited or upset. Some continue doing this for years. Since s/he has been going to school, has s/he tended to flap his/her arms when excited or upset? *

NoA little A lotNot Applicable

R38. You have answered a lot of questions about his/her pattern of development - focusing particularly on language, play, routines and his/her ability to get along with other people. Are you concerned at present about any of these aspects of his/her development? Please describe. *

NoA little A lot

R39. Thinking about the last 12 months, have difficulties in any of the areas that we have covered resulted in him/her becoming upset or distressed? *

Not at allA littleA medium amountA great deal

R41. Have these difficulties put a burden on you or the family as a whole? *

Not at allA littleA medium amountA great deal

R42. Some children's development is unusual from birth onwards. With hindsight, their parents realise that development was never quite normal. That's not always the case though. Sometimes parents are sure that development was completely normal for a while and then there was a relatively sudden change. Which was true for him/her? *

Always there to some extentSudden change

R43. How old was s/he when this change happened?

SENSORY INFORMATION

R44. Some children don't seem to react to pain or extreme heat or cold - sensations that would R44 bother most people. Has s/he ever seemed unconcerned about pain or other unpleasant sensations? *

NoA little A lot

R45. Some children are fascinated by particular sounds, smells and other sensations - and focus on them in an unusual way. Examples include: sniffing people, spending hours looking at the window frame at a particular angle, or looking at their own fingers against the light. Has s/he ever been really fascinated by particular sensations? Please describe. *

NoA little A lot

R46. Children may react surprisingly negatively to specific sounds, tastes, sights and so on. For example, some children get really upset by the sound of the phone ringing or people coughing. There are endless possibilities, but other examples include reacting particularly badly to the smell of a perfume, the taste of vanilla or the sight of a vacuum cleaner. Has ever been over-sensitive to particular sensations? Please describe. *

NoA little A lot

R47. Some children have an unusual response to touch. For example, they may overreact to touch (such as jumping if you put your hand on their shoulder, hate having their hair brushed or washed, or dislike the feel of labels/tags in clothing) or may not respond to things that others find uncomfortable (such as big strong bear hug, or squashing themselves behind furniture). Has s/he ever had unusual responses to touch? *

NoA little A lot

The above questions relate to specific diagnostic criteria in a DSM-V as indicated in the table below:

Code	DSM-V Criterion	Brief Description	Relevant Questions
Gen and Imp provide general information about development and impact of difficulties			R1, R2, R3, R4, R5, R6, R7, R8, R9, R38, R39, R40, R41, R42, R43
SE	A1	Socio-emotional reciprocity	R24, R25, R26
NV	A2	Non-verbal communication	R10, R11, R12, R28, R29, R30
Rel	A3	Relationships	R16, R17, R27
Rep	B1	Stereotyped and repetitive movement & behaviour	R13, R31, R32, R33, R37
RR	B2	Preference for routine and resistance to change	R34, R35, R36
OB	B3	Obessional behaviour and tendencies	R18, R19, R20, R21, R22, R23
Un	B4	Unusual interests and sensory responses	R14, R15
Sen	n/a	Sensory processing	R44, R45, R46, R47

CHILD'S HEALTH

Has he/she had any health problems? *

YesNo

Has he/she been in hospital? *

YesNo

Has he/she had any operations? *

YesNo

Is he/she on any medication? *

YesNo

Does he/she have any allergies? *

YesNo

FAMILY MEDICAL HISTORY

Please note the family member's relationship to the child in regard to the following:

Simply write N/A in the box if there is no relevant family history

Family relationship with Mental Illness (describe) *

Family relationship with ADHD *

Family relationship with ASD *

Family relationship with Suicide *

Family relationship with Drug or alcohol misuse *

Family relationship with Diabetes *

Family relationship with Epilepsy *

Family relationship with Cardiac Arrhythmia *

Family relationship with Sudden death *

Family relationship with Neurological disease *

Family relationship with Learning problems / special school / illiterate *

NICHQ Vanderbilt Assessment Scale

PARENT Assessment

Telecare acknowledges that it shall not claim to possess any right, title or interest in and to the Ritvo Autism Asperger Diagnostic Scale - Revised (RAADS-R) Assessment, and shall take no actions jeopardising the existence or enforceability of the proprietaryrights which Telecare recognises as belonging to the authors of the following assessment, as well as any other alleged proprietary holders hitherto unknown.

Instructions:

Each rating should be considered in the context of what is appropriate for the age of your child.When completing this form, please think about your child’s behaviors in the past 6 months.

Is this evaluation based on a time when the child: *

Was on MedicationWas not on medicationNot sure?

Symptoms

Performance

Comments:

Developer Reference:

Adapted from the Vanderbilt Rating Scales developed by Mark L.Wolraich, MD.Revised

Score

Symptom Score *

Performance Score *

Overall Score *

SNAP-IV 26 – Teacher and Parent Rating Scale

Source: James M. Swanson, Ph.D., University of California, Irvine, CA 92715

PRIVATE & CONFIDENTIAL

Completed by one or both guardians of a patient - Each person must complete their own form
Please complete all required fields and submit your form at least 72 hours prior to the patient's appointment. This form will be provided to the patient's specialist doctor.

PARENT Details

Your full name *

Relationship to the Patient *

Other *

Questionnaire SNAP-IV 26

Please select the most appropriate option that best describes the patient's behaviour

0 = Never or Rarely: This is not a problem or concern. Any challenges are/were age-appropriate

1 = Sometimes: Some difficulty (somewhat)

2 = Often: This is a problem (pretty much)

3 = Very Often: This is a serious problem (very much)

Often fails to give close attention to details or makes careless mistakes in schoolwork or tasks *

0123

Often has difficulty sustaining attention in tasks or play activities *

0123

Often does not seem to listen when spoken to directly *

0123

Often does not follow through on instructions and fails to finish schoolwork, chores, or duties *

0123

Often has difficulty organizing tasks and activities *

0123

Often avoids, dislikes, or reluctantly engages in tasks requiring sustained mental effort *

0123

Often loses things necessary for activities (e.g., toys, school assignments, pencils, or books) *

0123

Often is distracted by extraneous stimuli *

0123

Often is forgetful in daily activities *

0123

Often fidgets with hands or feet or squirms in seat *

0123

Often leaves seat in classroom or in other situations in which remaining seated is expected *

0123

Often runs about or climbs excessively in situations in which it is inappropriate *

0123

Often has difficulty playing or engaging in leisure activities quietly *

0123

Often is “on the go” or often acts as if “driven by a motor” *

0123

Often talks excessively *

0123

Often blurts out answers before questions have been completed *

0123

Often has difficulty awaiting turn *

0123

Often interrupts or intrudes on others (e.g. butts into conversations/ games) *

0123

Often loses temper *

0123

Often argues with adults *

0123

Often actively defies or refuses adult requests or rules *

0123

Often deliberately does things that annoy other people *

0123

Often blames others for his or her mistakes or misbehavior *

0123

Often touchy or easily annoyed by others *

0123

Often is angry and resentful *

0123

Often is spiteful or vindictive *

0123

Areas

Treatment Plan

Specialist: Please confirm if your child is booked to see this type of practitioner *

I understand that psychologists cannot diagnose and they cannot prescribe medications; Appointments are for therapy sessions. I understand I may therefore need to seek additional services for a diagnosis/treatment plan, including specialist care from a psychiatrist or paediatrician where separate fees apply. *

I confirm that I understand: Due to the limitation of telehealth services, most of our Psychiatrists and paediatricians are providing assessment and diagnostic services to hand over the ongoing care to your referring GPs.

The management of patients with attention deficit hyperactivity disorder (ADHD) may involve the prescription of restricted (S8) psychostimulant medications (e.g. Lisdexamfetamine/Vyvanse or Ritalin/Methylphenidate). Please be aware that while Telecare’s specialists may recommend treatment with such medications, but they will not provide the prescription for these medications (unless exceptional circumstances apply). Our psychiatrists/paediatricians are able to provide a supporting letter to your GP, detailing their recommendation for the medication. Your GP may then be able to use that recommendation to apply for a permit to prescribe these recommended medications.

I understand I must confirm with my referring GP that this is acknowledged and understood, prior to any telehealth appointment. We suggest that you confirm your GP can prescribe and has capacity to provide ongoing prescribing (which generally includes regular appointments for vitals measurements). Any queries, your GP/clinic can contact Telecare

SIGNATURE

I understand that Telecare and Telecare specialists are unable to provide any emergency assistance. If there is an emergency I will reach out to my GP or go to my nearest hospital or the local mental health service or the crisis team, or call 000 for emergency services *

I confirm the above information I have provided is true, complete and accurate. *

Access Telecare's Privacy policy here https://www.telecare.com.au/privacy-policy

Patient/ Guardian Signature *

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Today's Date *

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