Connecting Together Occupational Therapy Registration Form

Connecting Together Occupational Therapy Registration Form

Please complete this so that we can contact you to make a booking
Contact Details

Please complete all sections, this supports us to communicate with you and to find mileage for community travel to you
Parent Contact Details*

First NameLast Name
Phone Number: *
Child name:*
Child date of birth:*
Email*
example@example.com
Address: (please include so we can accurately calculate mileage)*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What school/daycare does your child currently attend?*
What made you contact us for Occupational Therapy services?

Gross Motor and/or Fine Motor skillsSensory ProcessingSelf-care skillsSocial skillsOther
What are some area/goals you have for you child in Occupational Therapy currently?*
Do you have public funding you wish to use for therapy sessions? e.g carer support, Child Disability Allowance CDA, Individualised Funding IF
Other
In choosing to use public funding I understand I may still be required to top up the invoices/charge to cover the cost for therapy sessions...*

Contact Details