Occupational Therapy Intake Form Logo
  • Occupational Therapy Intake Form

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  • 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.

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  • If under 18 0r unable to sign

  • I (parent/guardian name) consent to the above Terms and Conditions in relation to         (child’s/clients name)

  • Clear
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  • Should be Empty: