Therapy Assistant Program

Therapy Assistant Therapy Program

Provider Details

Name *

Clinic/ Practice name: *

Discipline *

Occupational TherapySpeech Language PathologistPsychologistPsychiatristPhysiotherapistPositive Behaviour Support PractitionerOther

Intervention history with child

Assessment onlyOngoing intervention 0-3 monthsOngoing intervention 3-6 monthsOngoing intervention 6-12 months Ongoing intervention 12 + monthsNo intervention

Provider Phone number *

Provider email: *

Personal information (about the child)

Child's First Name: *

Child's Last Name: *

Date of Birth *

Parents/ Carer's First Name: *

Parents/ Carer's Last Name: *

Parent/ Carer's Contact Number *

Parent/Carer's Email: *

Summary of clients diagnosis and medical history *

Behaviours of concern (if any)

HittingScratchingKickingBitingAbscondingShouting/ screamingSelf Harm/ injurious behaviour Task avoidance

Please describe more about the issues noted above including triggers

Areas of Difficulty

Priority Goal 1 *

Priority Goal 2 *

Priority Goal 3

Other Comments/ areas of concern

Therapy Home Program

Activities to complete *

Additional notes

Frequency per week *

1 x per week 2 x per week3 x per week4 x per week

Recommended location *

HomeSchoolDaycare/ kindyCommunityClinic

Preferred ongoing reported method *

Shared session notes via emailCase meeting with TAPhone call with supervising therapist

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