Telehealth Questionnaire
Please complete at least 24 hours prior to your first session.
Patient Name
*
First Name
Last Name
Parent Name
*
First Name
Last Name
Email address
*
Best Phone Number
*
NAPA Clinic
Sydney
Melbourne
Brisbane
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Availability
Please select the times and days in which you are available.
Monday
Morning (8am -12pm)
Afternoon (12.30pm - 3.30pm)
Other
Tuesday
Morning (8am -12pm)
Afternoon (12.30pm - 4.30pm)
Other
Wednesday
Morning (8am -12pm)
Afternoon (12.30pm - 4.30pm)
Other
Thursday
Morning (8am -12pm)
Afternoon (12.30pm - 4.30pm)
Other
Friday
Morning (8am -12pm)
Afternoon (12.30pm - 3.30pm)
Other
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What type of therapy are you hoping to arrange Telehealth sessions for? (Tick all that apply)
Physiotherapy
Occupational Therapy
Speech Therapy
Feeding Therapy
Who will be facilitating your session from home?
Mum, Dad, Carer?
Do you have any specific areas you would like to target during your session? (include previous Home Exercise Program Activities you would like to review)
If participating in PT or OT, please list any materials and/or equipment you have available to use.
eg. Mat, table, gym balls, arm wraps, boxes etc
Please list specific toys, activities, or games you have that are motivating for your child & would like to utilise.
Please list any Assistive Technology/communication devices you would like your therapist to review?
including gait trainers, walkers, standing frames, seating systems, orthotics, AAC etc
List any other information that would be helpful to you for future sessions.
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