Excel OT New Client Intake Form

NDIS Waitlist Submission Excel OT
Clients Name*

First NameLast Name
Client's DOB*
Gender*
Female/male/other
Client's School/workplace and year level*
Parent/Carer Name #1*

First NameLast Name
Parent/Carer Name #2

First NameLast Name
Do any other family members currently or have previously accessed OT with Excel?*
Please provide details if possible
Home address*
Email Address*
Phone Number*
Cultural and ethnic background
Does the client/family identify as Aboriginal or Torres Strait Islander?
Does the client/family require an interpreter to access services? If yes, please provide further details.
Are there any religious or cultural practices your family observes that you would like us to know about?
Who is completing this form? *
Including relationship to client
Contact number of person completing this form. *
How will the client be funding services?*
Do you have NDIS Funding?*
NDIS Participant Number
How is your NDIS plan managed?

Self managedPlan managed
If plan managed who is your plan manager?
NDIS plan dates
Goals for Therapy
What service do you require?*

Ongoing therapy to support skill developmentAssessment (Eg. Functional Capacity Assessment, Sensory Assessment, Handwriting Assessment)
Please comment on the type of assessment you require if known
If you could pick three things to work on in OT, what would they be?*
Child's Medical History
Diagnosis*
Any relevant medical history/allergies
Custody/Guardianship
Child lives with*
If other, please specify
Is a parenting or restraint order applicable? Eg. Guardianship
Please list any other special family circumstances of which Excel OT should be aware of to provide maximum support.
Please provide the names and contact details of other adults who may be involved in therapy.
For example, grandparents or support workers dropping client off to therapy sessions
Date form completed

DayMonthYear
Date
Should be Empty:

NDIS Waitlist Submission Excel OT

Goals for Therapy

Child's Medical History

Custody/Guardianship