NDIS Waitlist Submission Excel OT & Speech Pathology
Clients Name
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First Name
Last Name
Client's DOB
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Gender
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Female/male/other
Client's School/workplace and year level
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Parent/Carer Name #1
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First Name
Last Name
Parent/Carer Name #2
First Name
Last Name
Do any other family members currently or have previously accessed therapy with Excel?
*
Please provide details if possible
Home address
*
Email Address
*
Phone Number
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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?
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Including relationship to client
Contact number of person completing this form.
*
How will the client be funding services?
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Please Selecti
NDIS
Private Health Fund
Privately paying
Medicare Plan (CDM/EPC)
Do you have NDIS Funding?
*
Please Selecti
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
Please select the service/s you wish to be added to the waitlist for.
Occupational Therapy
Speech Pathology
Occupational Therapy
What OT 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 OT assessment you require if known
If you could pick three things to work on in OT, what would they be?
Has your child ever seen an OT before?
Speech Pathology
What speech service do you require?
Ongoing therapy to support skill development
Assessment (e.g. language assessment, speech assessment, literacy assessment )
Please comment on the type of speech assessment you require if known
What area of support does your child/teen need?
Speech clarity
Saying sounds (e.g. “d” instead of “g”)
Saying words and sentences
Not yet talking / using few words
Understanding language
Social skills / interacting with others
Stuttering
Child and adolescent voice therapy
Reading
Writing
Please tell us as much as you can about how you’d like us to help your child.
Has your child ever seen a speech pathologist before?
What clinic would be your preference for Speech appointments?
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Coffs Harbour
Woolgoolga
Either
Child's Medical History
Diagnosis
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Any relevant medical history/allergies
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
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