Adventure Therapy Enquiry Form

Adventure Therapy Services Enquiry Form
Your details:
Who is filling in this form today?*

Your First NameYour Last Name
What is your relationship to the person requiring OT services?*
Your Email*
example@example.com
Your Phone Number*
Please enter a valid phone number.
Is your contact details different to the person requiring support?*

YesNo
How did you find out about us?*
Who referred you to us e.g. GP, support coordinator, other NDIS representative, family friend.

Client Details (the person requiring OT services):
Client Full name:*

First NameLast Name
Date of Birth:*

DayMonthYear
Date
Gender:*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Client's Residential Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client's Kindergarten / School / Workplace / Day Program
Does the client have a diagnosis?*

YesNo
Please list:*
Please list what the diagnoses are and when they were diagnosed (e.g. what year or how old they were).

Select how much difficulty the client has in the following functional areas:*

	No difficulty	Mild difficulty	Moderate difficulty	Severe difficulty	Cannot do this
Generally understanding what people say
Telling your family or friends about things you have done, people you've met, or places you've been
Walking for as long a distance as other people your age can
Dressing, bathing and brushing your teeth with an age-appropriate level of assistance
Doing chores or other things you are expected to do at home
Joining in on community activities

Describe the main issues or struggles the client is having in day to day life?*
Are there safety concerns?*
e.g. falls, urgent equipment requests, self-harm
Describe safety concerns*
E.g. risk of harm to self, panic or anxiety attacks, risk of harm to others, inappropriate environment, inappropriate equipment, risk of absconding
Are there any allergies we should be aware of?*
e.g. environmental allergies (like pollen, dust or insects), food allergies (likes nuts, dairy or shellfish)
Describe allergy & management
E.g. the type of reaction experienced, preventative measures in place, medication carried
Please identify any supports currently available to the client:

NoneFamily and friend support onlyPsychologySpeech PathologyPhysiotherapy/Exercise PhysiologySupport WorkersNDIS Support CoordinatorOther

Important Information
We send text messages for appointment reminders, is this okay?*

This is okayThis is not okay
We value our role in environmental sustainability, and prefer to send clinical correspond via email. Is this okay?*

I am happy to receive information including clinician correspondance and documents via emailI do not wish to be sent information via email, you will need to post correspondance instead.
Please Note:

Unless you are an adult client, we recommend that Parent Coaching appointments occur once every 4 weeks (monthly) and it is required once every 12 weeks (minimum). In the case of adult clients, often care team meetings are facilitated in place of parent coaching. Please see our website for further information on Parent Coaching and all of our services.
Client Declaration:

I confirm that I am the client listed above, their legal guardian or I have the authority to consent to the services listed above. This is a private provider, and fees do apply for services. Applicable fees will be discussed prior to commencement of services.
Do you agree?*

YesNo
Is there any other information that would be helpful for us to know?
IMPORTANT

You will receive an email from Adventure Therapy Services confirming that we received your submission.

To avoid this email and any other correspondence from Adventure Therapy Services going to your junk folder, please add hello@AdventureTS.com.au to your contact list.
Should be Empty:

Adventure Therapy Services Enquiry Form