Allied Health Expressions of Interest
Penrith Childcare Services are taking expressions of Interest for Occupational Therapy and Speech Therapy services.
Client Details
Please complete the below details for the child
Child Name
*
First Name
Last Name
Child Date of Birth
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-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Child Gender (optional)
Parent/Carer/Guardian Name
*
Relationship to Child
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Contact Number
*
Email Address
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Referral Information
Who is completing this form?
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Parent/Carer/Guardian
Support Coordinator
GP
School
Advocate
Other
If you have selected 'Other' please provide your name and role
If you have selected 'Other' will you remain the primary contact person?
Yes, contact me for bookings
No, contact the parent/carer/guardian
Have you attended our services previously, or are an existing client?
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Yes
No
Service Requested
Which service(s) are you interested in?
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Speech Therapy
Occupational Therapy
Both Speech Therapy and Occupational Therapy
Counselling or Parent Support
Reason for Referral
Speech Therapy
What concerns would you like support with?
Speech sounds/pronunciation
Language development
Understanding language
Expressing wants, needs and ideas
Following instructions
Social communication
Stuttering
Literacy
Feeding/eating
Alternative communication (AAC)
Voice
Oral function (e.g, mouth breathing, thumb sucking)
Other
Please describe your concerns and goals/outcomes for speech therapy
Occupational Therapy
What concerns would you like support with?
Fine motor skills
Handwriting
Self-care skills
Sensory processing
Emotional regulation
Attention/concentration
Play skills
Gross motor coordination
School readiness
Functional independence
Other
Please describe your concerns and goals/outcomes for occupational therapy
Counselling/Parent Support
What concerns does your child need support with?
Emotional identification and expression
Self-esteem and confidence
Rigidity and black and white thinking
Low mood
Anxiety
Assertiveness
Social and play skills
Managing changes and transitions
What concern would you as a parent/carer/guardian like support with?
Supporting and managing behaviours at home
Balancing daily life and therapy implementation
Parent self-regulation and support
Understanding diagnoses
Managing Carers stress and wellbeing
Balancing routine
Supporting sibling relationships
Assertiveness and confidence navigating systems around your child
Grandparent support - navigating goals and carer support for your grandchild who has a disability
Would you be interested in:
Counselling for your child
Parent support and coaching
Both
Please describe your concerns and goals/outcomes for counselling or parent support
Current Circumstances
Has your child lost or stopped using a skill they previously had in the last 3 months (e.g. words they used to say, walking, toileting, feeding themselves)?
Yes
No
If yes, please briefly describe what changes and when you first noticed it
Is your child due to start school within the next 6 months?
Yes
No
Is this the first time your child is accessing any allied health support (occupational therapy, speech therapy, physiotherapy, psychology)?
Yes
No
Is your child currently unsupported by any therapy intervention related to your current concerns?
Yes
No
Would you say the concern is having a significant impact on your, or your child's safety and wellbeing?
Yes
No
Is your family currently connected with any of the following? (select all the apply)
GP
Pediatrician
Early childhood nurse
Family support worker
Another allied heath service
Support coordinator
None of the above
Diagnoses and Medical Information
Does your child have any formal diagnoses?
*
Yes
No
If yes, are there any medical conditions impacting participation?
Any allergies or relevant risks?
Needs and Supports
What language is primarily spoken at home?
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Does your child speak a language other than English?
*
Yes
No
If yes, please specify:
Is an interpreter required for appointments?
Yes
No
Unsure
If yes, preferred language is:
Preferred dialect (if applicable):
Preferred interpreter gender (if applicable):
Will a family member/friend be assisting with interpretation?
Yes
No
Do you or your child have any support, communication, sensory, cultural or accessibility needs that we should know when delivering services?
*
Does your child have a behaviour support plan, or is initiating Specialist behavioural support?
*
Yes
No
Does the behaviour support plan include restrictive practices?
*
Yes
No
Does not have a behaviour support plan
Are there any risks or hazards that may occur when delivering our services that we need to be aware of (e.g physical aggression or leaving supports / running away)?
*
Yes
No
If yes, describe risk/hazards:
Funding Information
How will therapy be funded? Please note, counselling is only funded via NDIS or private paying
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NDIS - Capacity Building 'Improved Daily Living' budget
Medicare
Private Health Insurance
Private Paying
If NDIS funded, please provide the child's NDIS number:
Payment Type
Plan managed
Self-managed
Plan start AND end date:
Funding amount available for therapy supports:
Payment Information NDIS rate is currently $193.99 per hour for allied health services and $156.16 per hour for counselling. Payment will need to be made on the day of service, and an invoice will be sent to you to be reimbursed by your plan manager or the NDIS (if self-managed). Please check your funding amount before booking to ensure there are relevant funds for service. A completed service agreement and consent form will need to be signed before your initial session, and this will be sent to you when a booking is confirmed. Medicare/Private paying clients will be charged $222.00 per hour for allied health services. Payment will need to be made on the day of service. If seeking a Medicare rebate, a Medicare EPC/CDM plan will need to be sent with the completed service agreement before the initial session. This is referred by a GP.
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I understand and acknowledge the payment policy
Availability
What days are preferred?
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Monday
Tuesday
Wednesday
Thursday
Friday
Preferred times:
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Morning
Afternoon
After school
No preference
Specific time
If you have selected 'specific time', please provide your preference:
Consent
By submitting this form, I agree that Penrith City Council may collect and securely store the information I provide for the purpose of allocating and commencing services. I understand that my information will only be accessed by staff who need it to support service delivery.
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I agree
I agree to be contacted by phone, email or SMS regarding appointments, waitlist updates and service availability.
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I agree
I understand that submitting this form places me on the waitlist for services. When an appointment becomes available, Penrith City Council will contact me to offer a booking. I understand that I will have 48 hours to respond to this offer. If I do not respond within 48 hours, I may be returned to the waitlist and contacted again when another appointment becomes available.
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I understand
I understand that I can request to be removed from the waitlist at any time by contacted the Penrith City Council Allied Health Team.
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I understand
I have read and understood the above information and provide my consent.
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I understand
Submit
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