Child Application Form
Primary Contact Information
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Relationship to client
*
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Client Details
Name
*
First Name
Last Name
Birth Date
*
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2025
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Year
Gender
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Funding *Please note we are unable to service NDIA managed clients
*
NDIS Self-managed
NDIS Plan-managed
Privately Paying
Health Fund
CDM
If NDIS Plan-managed, please provide the Plan manager name and NDIS number
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
Where do you prefer the sessions to take place? (Please tick all that apply)
*
Clinic (Penrith)
School
Daycare
Home
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.
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If school or daycare, please provide details
Please provide your child's diagnosis in detail. For example 'ASD Level 1, ASD Level 2, GDD, ADHD, etc '. Please state if diagnosis is unknown.
*
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
How does your child communicate?
*
Speaking
Non-speaking
Do you have any behavioural concerns for your child? If yes, please detail any behaviours that concerns you
*
Do you feel your child would benefit from peer or group therapy sessions?
*
Yes
No
Would you like to be considered for upcoming school holiday programs?
*
Yes
No
Please confirm your child's full availability for sessions (Please note, higher availability will reduce wait time)
*
Why is OT important to you and your family?
*
How did you hear about us?
*
Please upload any relevant documents (e.g. reports, goals, NDIS plan)
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