Intake form

New Client Intake Form

Your details

Your Full Name *

What is your relationship to the child? *

Personal Information (about your child)

Child's First Name *

Child's last name *

Date of Birth *

Child's Address *

Current Diagnosis and Medical conditions (if any) *

Current Medications (if any) *

Current school/ Early Learning centre *

Family members living at home (please include names and ages) *

Are there any Family Law Proceedings we should be made aware of? *

YesNo

Functional Concerns

Priority 1 concerns (please include as much detail as possible) *

Priority 2 concerns *

Priority 3 concerns

Other comments/ areas of concern (list if necessary)

Child's History

GP Name, clinic and contact details

Please note name and contact details

Does your child have a Behaviour Support Plan?

YesNo

Does your child have any allergies? *

YesNo

What is your child allergic to? (if any)

In Case of Emergency

Contact Name *

Contact number *

Relationship to the child? *

NDIS Participant Information

NDIS Participant Number *

Funding type *

Plan managedSelf managed

Plan Manager Contact details

Declaration and Consent Forms

By using your electronic signature to sign this document, you declare you are the child's parent/ legal guardian (as noted in your details) *

YesNo

By using your electronic signature to sign this document, you consent in full to the sharing of history, personal details, diagnostic results and clinical observations with other providers (as noted in child's history) *

YesNo

Please note any exceptions to your consent to share information

By using your electronic signature to sign this document you consent to your child commencing services with Therapy Assistance and Support Services *

YesNo

By using your electronic signature to sign this document you agree to pay for Therapy Assistant and Support services as per the payment policy in the Service agreement *

YesNo

By using your electronic signature to sign this document, you understand that sessions cancelled late (with less than 24 hours notice) or that are not attended without notice are billed for the full cost of the session including travel and other associated costs *

YesNo

By using your electronic signature to sign this document, you agree to not leave the location of your child's therapy session unless pre-approved by the Program Manager *

YesNo

By using your electronic signature to sign this document, you consent to photos of your child being used on Therapy Assistance and Support Services social media *

YesNo

Patient/ Guardian Signature

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Full Name *

Relationship to the child *

Today's Date

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