Occupational Therapy Intake Form

Occupational Therapy Intake Form
Name

First NameLast Name
Date Of Birth

MonthDayYear
Date
Gender

MaleFemaleOther
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile
Email
example@example.com
Phone
Do you have a pension card?

YesNo
Do you have private health insurance?

YesNo
If yes, please provide name and card number
Doctor/Referrers name?
Medicare Number and expiry date
Emergency Contact
Emergency Contact Number
Please enter a valid phone number.
Relationship to Client?
If under 18, please state parents/guardian name

First NameLast Name
If under 18, please list the school of attendance
What is the reason for presenting to Cross Care today?
How long have you been experiencing this problem?
REASON FOR REFERRAL:

NDIS Functional AssessmentSelf-CareHome ModificationsAssistive Technology/EquipmentIADLsGross MotorFine MotorSensory RegulationVisual PerceptionEmotional RegulationHandwritingSocial Skills
List of medications
Do you have or ever had

DiabetesDislocationsPregnantRheumatoid arthritisSpinal traumaHeart complicationsPacemakerOsteoarthritisOsteoporosisHigh blood pressureJoint replacementsRecent nauseaBladder/Bowel issuesDizzinessCartilage injuriesAnkylosing spondylitisLigament injuriesImplantsUnexpected weight lossSpinal surgeryStrokesSpinal fractureAneurysmCancers
W: www.crosscarendis.com.au E:admin@crosscarendis.com.au

P: 02 8074 1888 M: 0416 204 394

By signing this form, I hereby give my consent for:

• The participant to receive Occupational Therapy services from Cross Care and agree to pay all associated fees, including a Medicare Gap, for these services in accordance with Cross Care policies

• Cross Care to contact and share information and reports with educational staff, medical practitioners, specialists and health professionals involved in the participants care

• If the client is a child, I understand and agree that physical guidance contact between my child and their treating Occupational Therapist as necessary. I acknowledge that all care is taken whilst working with my child however physical contact may be required for guidance during therapy sessions, and that such contact will only be used to ensure the best outcome for the individual. I understand physical guidance may involve hand-over-hand prompting, guiding the individual into a seated position etc.

In addition, by signing below, I confirm that I understand and agree:

• To pay all fees and charges for the individuals Occupational Therapy services on or before the date of the session

• If applicable, I am to be present for at least the first 5 minutes, and last 10 minutes, of my child’s session unless otherwise advised/agreed

• If applicable, I am responsible for supervising my child/ren whilst at Cross Care
The above must be at least 18 years of age, otherwise consent from a custodial parent is required to treat a minor. Your signature confirms that you have read and give consent to Cross Care Clinic Policy.
Signature

Clear
Date

MonthDayYear
Date
If under 18 0r unable to sign
I blanks (parent/guardian name) consent to the above Terms and Conditions in relation to First Name Last Name (child’s/clients name)
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Occupational Therapy Intake Form

If under 18 0r unable to sign