Connecting Together Occupational Therapy Registration Form

Connecting Together Occupational Therapy Registration Form

Please complete this so that we can contact you and 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
Contact Details

First Name Last Name
Phone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

City State / 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 skills Sensory Processing Self-care skills Other

Important Information

Please review the service agreement and the COVID screening form attached, you will be asked to sign the service agreement in your first session, but here you can pre-read it to ensure you agree to the terms of service
Connecting Together service agreement
COVID Appointment Screening Form
I have read the service agreement

Yes
I have read and completed the COVID appointment screening form

Yes
I will sign the service agreement in our first session..

Yes
Should be Empty:

Contact Details