Therapy Assistant Request
This includes the information we need to start the process of pairing your child with the right Therapy Assistant. If your child does not currently attend sessions with a Playology Clinic therapist and you are interested in seeking Therapy Assistant Support, please call our Client Care Team (03 9752 1571 or send an email admin@playologyclinic.com.au) to discuss further.
Please complete all information below:
Child's Name
*
First Name
Last Name
Email of parent/guardian
*
example@example.com
Child's Date of Birth
*
-
Day
-
Month
Year
Date Picker Icon
Where would you like the Therapy Assistant to support your child/client?
*
Home
Childcare
Kindergarten
School
Other
If you clicked "Childcare" "Kindergarten" or "School" in the above question, please fill out the details below
Otherwise, please skip to the next section
Name of contact at Childcare/Kindergarten/School
First Name
Last Name
Email of contact at Childcare/Kindergarten/School
example@example.com
Phone Number of contact at Childcare/Kindergarten/School
Please enter a valid phone number.
Format: (000) 000-0000.
Address of Childcare/Kindergarten/School
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Has the childcare/kindergarten/school consented to Therapy Assistant support?
YES - The child's childcare/kindergarten/school has provided written consent to a Therapy Assistant attending at that setting
NO - The child's childcare/kindergarten/school has not provided written consent as yet to a Therapy Assistant attending at that setting. (Please note that we require a child's parent/guardian to obtain permission from the relevant setting prior to a Therapy Assistant being allocated). If you are unable to contact your child's school, our Client Care Team can assist you with this.
If you have not yet obtained written consent from your child's childcare/kindergarten/school, please select one of the following
Parent/Guardian consent to the Playology Client Care Team contacting the child's educational setting to seek permission
Parent/Guardian will contact school via email and forward reply to Client Care Team (admin@playologyclinic.com.au)
How often would you like Therapy Assistant sessions (for NDIS participants, please consider your "Improved Daily Living" funding - it's the same pool of funds as other therapies)?
*
Weekly
Fortnightly
Less often than fortnightly
Multiple times per week
What days/times would your child/client be available for Therapy Assistant sessions?
Therapy Assistants are available Monday to Friday, between the hours of 9am and 6pm.
Your availability (tick = available within this window):
Rows
Morning
Afternoon
Monday
Tuesday
Wednesday
Thursday
Friday
What would you like a Therapy Assistant to help your child with?
*
Examples: emotional regulation, social skills, communication, confidence, daily living skills, school participation, following routines, independence, practising strategies recommended by your child's therapist etc.
How were you referred to the Therapy Assistant service?
*
I am a parent/guardian referring my child.
My child's therapist asked me to complete this referral (Please enter your child's therapist's name in the next question)
I am the treating therapist completing this referral on behalf of a parent/guardian.
If your child's therapist referred you to complete this form, please write the therapist's name below
First Name
Last Name
Thank you for completing this form
Our client care team will be in contact with you once we find the right Therapy Assistant that can support your child/client with their goals.
Full name of person completing this form
*
First Name
Last Name
Submit
Should be Empty: