Client Intake Form

Client Intake Form

Client Intake Form
Name of Participant:

First NameMiddle NameLast Name
MaleFemaleOther
Date of Birth:

DayMonthYear
Age:
Parent/Guardian/Carer Name:

First NameLast NameRelationship to child
Parent/Guardian/Carer Name:

First NameLast NameRelationship to child
Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry of birth
Home Language:
Phone number:
Format: 0000-000-000.
Email:
YesNo
Location of Service Delivery:
Preferred time for therapy sessions:
Funding Scheme: (if any)
Self ManagedPlan ManagedPortal Managed
Diagnosis: (if applicable)
Date of diagnosis:

MonthDayYear
Date

Supports Involved:

Rows	Name and Contact Details (if known)
Paediatrician/GP
Specialist
Teacher (include school and grade)
Allied Health (OT, Speech, Dietician, Physio, Psychologist)

Please outline areas of concern and reason for referral to Occupational Therapy:
e.g. fine motor coordination, toileting, emotional regulation etc.
Should be Empty: