Allied Health Client Application Form
Services
Please indicate which service(s) you are interested in (tick all that apply):
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Paediatric Occupational Therapy (0-18 years)
Dietetics (Child or Adult)
Speech Therapy
Psychology
Who will be the client receiving services?
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Child / Teenager (under 18 years)
Adult
Client Details
Name
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First Name
Last Name
Birth Date
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Please select a day
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Day
Please select a month
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Month
Please select a year
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Year
Gender
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number (If the client is a child, please provide the parent/guardian’s contact number)
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-
Area Code
Phone Number
Email (If the client is a child, please provide the parent/guardian’s email address)
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example@example.com
Parent / Guardian Details (Required for Paediatric Services)
If the client is an adult accessing Dietetics services, please skip this section.
Primary Parent/Guardian Name:
First Name
Last Name
Relationship to Child:
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Occupational Therapy – Service Information (Complete if requesting OT, Otherwise, please skip to the next page.)
Please indicate which services you are interested in for your child
Individual Sessions
Peer-paired Sessions
Group Sessions
Functional Capacity Assessment (FCA)
Functional Capacity Assessment (FCA) with ongoing sessions
Sensory Assessment + report
Initial Assessment + report
Where do you prefer the sessions to take place? (Please tick all that apply)
Clinic (Penrith)
School
Daycare
Home
If school or daycare, please provide details
Who would you like sessions to held with? (Please tick all that apply)
Occupational Therapist (OT)
Occupational Therapy Assistant (OTA)
Therapy practitioner with the earliest availability
What is an OT?
- OT (Occupational Therapist) is a fully accredited Occupational Therapist holding AHPRA registration
What is an OTA?
- OTA (Occupational Therapy Assistant) holds a Degree in Health Science and is currently in progress of obtaining Occupational Therapy degree. The initial appointment is conducted by the OTA and is supervised by the OT for technical questions that may not be able to be answered by the OTA. The OT will plan sessions and the OTA will administer the activities and make appropriate observations which will be reviewed by the OT.
OT & OTA
Both the OT and the OTA offer an all-rounded therapeutic approach, targeting and supporting participant's goals.
Diagnosis & Medical Information
Please provide your child's Please diagnosis in detail. For example 'ASD Level 1, ASD Level 2, GDD, ADHD, etc '. Please state if diagnosis is unknown.
Main Concerns & Reason for Referral
Please outline your main concerns and reasons for referral to OT:
Fine motor e.g. difficulty holding objects, using utensils
Handwriting skills e.g. letter formation, spacing, alignment
Self-care skills e.g. showering, dressing, toileting, grooming, feeding
Gross motor skills e.g. coordination, balance
Executive functioning e.g. difficulty with planning, organising, problem solving
Self-regulation e.g. trouble managing emotions and behaviours
Sensory processing e.g. sensitivity or aversion to sensory stimuli
Attention and engagement
School readiness
Early intervention e.g. joint play, crawling, drawing
If not listed above, please detail any other concerns/reasoning to use OT services
Do you have any behavioural concerns for your child? If yes, please detail any behaviours that concerns you
Additional Information
How does your child communicate?
Speaking
Non-speaking
Do you feel your child would benefit from weekly/fortnightly peer or group therapy sessions?
Yes
No
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Dietetics – Additional Information (Complete if requesting Dietetics, Otherwise, please skip to the next page.)
Primary reason to see a Dietician (e.g. fussy eating, weight concerns, medical condition, family nutrition, general wellbeing):
Please list any relevant diagnoses, allergies, or medical conditions:
Speech Therapy – Additional Information (Complete if requesting Dietetics, Otherwise, please skip to the next page.)
Primary reason to see a Speech Therapist (e.g. speech sound errors, late talking, limited vocabulary, stuttering, voice concerns):
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All Services
Service Funding
*
NDIS plan managed
NDIS self managed
Health fund
CDM
Private Paying
If NDIS Plan-managed or using a Health Fund - please provide the details below:
Please confirm your or your child's full availability for sessions (Please note, higher availability will reduce wait time)
*
How did you hear about us?
*
Please upload any relevant documents (e.g. reports, goals, NDIS plan)
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