Village Therapy Waiting List Form

Sunbury: Shop 1, 106-126 Gap Road Sunbury VIC 3429

Ph: 9811 7026

Fax: 8677 9098

reception@villagetherapy.com.au
Village Therapy Client Form

This information helps us greatly to ensure you are allocated to an appropriate therapist/Support Coordinator. It will mean we can provide targeted therapy/Support Coordination that saves you time and money.
What therapy type(s) are you looking for?:
Please note our Occupational Therapy Waiting List is now closed. If you would like to be notified when it opens, please click on the link below and complete the form. Unfortunately we cannot add you to our OT waiting list at this time.

Notify me when the Occupational Therapy Waiting List is Open
Client Details

Person receiving therapy or Support Coordination
Please select which option is applicable:
Please note our Occupational Therapists only see Paediatric clients. Please do not continue with this form if you are an adult seeking Occupational Therapy.

Our Speech Pathologists see both Paediatric and Adult clients.
Name of Person receiving Therapy or Support Coordination:

First NameLast Name
Preferred Name
Pronouns

Other
Date of birth:

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client's Email
example@example.com
Client's Phone Number

Area CodePhone Number
Occupation
Hours of Work
Who is filling out this form?
What is your name?
What is your relationship to the client?
Please provide your Phone Number as the person completing this form:

Area CodePhone Number
Please provide your email as the person completing this form:
example@example.com
Parent/Guardian Name:
Parent/Guardian relationship to the client?
Eg. Mother, Father, Foster Carer etc
Parent/Guardian Phone Number:

Area CodePhone Number
Parent/Guardian Email:
example@example.com
What does the client's communication look like? (If you are the client, please complete from your perspective). Please select any/all that apply.
As a provider that specialises in disability, we see a number of clients that are immuno-compromised. For this reason, we require all of our clients to be fully immunised, and to provide evidence of such. Please tick below to indicate that you agree to provide a copy of your child’s current immunisations either before the appointment or on the day of the appointment.
Appointments
How would you like us to communicate with you to arrange appointments?

Other
Who is the person responsible for making appointments for this client?
Please provide the full name of the person making appointments for this client
What is their relationship to the client?
Please provide the phone number of the person responsible for making appointments for this client.

Area CodePhone Number
Please provide the email address of the person responsible for making appointments for this client.
example@example.com
Has the person receiving therapy/Support Coordination received a previous diagnosis for anything medical, developmental, neurological/neurodivergence or other? Are they currently being assessed for any of these? If so, please indicate below:
Please note our triage list for Occupational Therapy is currently closed. We are unable to add you to this list at this time. Please refer to our Facebook Page for updates.
Please note our triage list for Music Therapy is currently closed. Please refer to our Facebook Page for updates.
Speech Pathology
While you are waiting on a spot with a Speech Pathologist, would you be interested in receiving therapy from an Allied Health Assistant (ie. a Speech Pathology student) at a reduced rate?:

Other
Relating to Speech Pathology: are you looking for an assessment or ongoing therapy? (tick both boxes if you would like both options):

Other
What sort of assessment are you looking for (if known)?
Please note our triage list for ongoing Speech Pathology is currently closed. We are unable to add you to the list for ongoing therapy at this time. Please refer to our Facebook Page for updates.
What concerns have led you to seek the assistance of a Speech Pathologist?
What affect is this having on your daily life?
What sort of Speech difficulties are they presenting with?

Other
You have selected that they present with difficulties with Using Language. Please provide us with more information below:

Other
You have selected that they present with difficultes with Social Skills. Please provide us with more information below:
You have selected that they present with difficultes with Swallowing/Mealtimes. Please provide us with more information below:
Occupational Therapy
Relating to Occupational Therapy: are you looking for an assessment or ongoing therapy? (tick both boxes if you would like both options):

Other
What sort of Occupational Therapy Assessment are you looking for (if known)?
For ongoing Occupational Therapy, what are some of the areas you would like assistance with?

Other
Tell us in your own words, what has prompted you to seek the assistance of an Occupational Therapist? What are your concerns?
What impact is this having on your daily life?
Music Therapy
For ongoing Music Therapy, what are some of the areas you would like assistance with?

Other
Tell us in your own words, what has prompted you to seek the assistance of a Music Therapist? What are your concerns?
Funding
Are you a current client at Village Therapy (of any therapy type)?

Other
Relating to Funding, please answer the most applicable.
Do you have a concession card?
What type of funding do you have?

Other
Please note that services at Village Therapy require payment on the day of the appointment. Please click to indicate you understand this.
Please note that the NDIA and Allied Health bodies strongly recommend provision of the client's NDIS Plan and completion of a Service Agreement for all clients. Village Therapy abides by this recommendation.

All clients are required to provide a copy of their NDIS plan (goals only if preferred) and sign a Service Agreement in order to receive therapy.
Please tick below to indicate you agree to provide a copy of the client's NDIS plan and sign a Service Agreement.
Does the client have a history of triggered or dysregulated behaviour? Some examples might be; shouting, hitting, withdrawing, meltdowns etc. Knowing about this helps us find you the right clinician.
What happens in the lead up to this behaviour? (ie. what triggers it?)
eg; loud noise, lots of people, coping with change in routine, frustration etc
What does this behaviour look like when it happens?
eg. hitting, biting, kicking, shouting, meltdowns etc
What strategies to do you use when this happens? How effective are they?
eg. redirection/distraction; regulating activities such as video games or deep pressure etc
Are there any court orders in place relating to the client? If so, please provide information about this and forward a copy of the court order as soon as possible.
Can you give us 3-4 sentences describing the client? What do you/they like to do? What are your/their strengths?
Is there anything else you would like to let us know?
Should be Empty:

Village Therapy Client Form

Client Details

Appointments

Speech Pathology

Occupational Therapy

Music Therapy

Funding