Referral 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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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
Private paying
If NDIS funded, please provide the NDIS number and plan date
Where do you prefer the sessions to take place? (Please tick all that apply)
*
Clinic (Penrith)
School
Daycare
Home
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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:
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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
Please confirm your child's full availability for sessions (45 mins).
*
Why is OT important to you and your family?
*
Please upload any relevant documents (e.g. reports, goals, NDIS plan)
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