Excel OT Waitlist Submission
Clients Name
*
First Name
Last Name
Client's DOB
*
Gender
*
Female/male/other
Client's School/workplace and year level
*
Parent/Carer Name #1
*
First Name
Last Name
Parent/Carer Name #2
First Name
Last 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
*
Does the client/family require an interpreter to access services? If yes, please provide futher details.
Who is completing this form?
*
Including relationship to client
Contact number of person completing this form.
*
How will your/ the client's be funding services?
*
Please Select
NDIS
Private Health Fund
Privately paying
Medicare Plan (CDM/EPC)
Do you have NDIS Funding?
*
Please Select
Yes
No
NDIS Participant Number
How is your NDIS plan managed
Self managed
Plan 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 development
Assessment (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
Relevant family medical history
Custody/Guardianship
Child lives with
*
Please Select
Both parents
Shared custody
Parent 1
Parent 2
Other
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
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Day
-
Month
Year
Date
Submit
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