Excel OT Waitlist Submission
Parent/Carer Name #1
Parent/Carer Name #2
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?
Private Health Fund
Medicare Plan (CDM/EPC)
Do you have NDIS Funding?
NDIS Participant Number
How is your NDIS 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
Any relevant medical history/allergies
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
Date form completed
Should be Empty: