Private/ Medicare Waitlist Submission Excel OT and Speech Pathology
This form is for clients who are privately funded or using Medicare rebates to fund services.
Are you adding your child on the list for Speech Pathology or OT services?
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Speech Pathology
Occupational Therapy
Both
Clients Name
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First Name
Last Name
Client's DOB
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Gender
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Female/male/other
Client's School/workplace and year level
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Parent/Carer Name #1
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First Name
Last Name
Parent/Carer Name #2
First Name
Last Name
Do any other family members currently or have previously accessed services with Excel?
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Please provide details if possible
Home address
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Email Address
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Phone Number
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Cultural and ethnic background
Does the client/family identify as Aboriginal or Torres Strait Islander?
Does the client/family require an interpreter to access services? If yes, please provide further details.
Are there any religious or cultural practices your family observes that you would like us to know about?
Who is completing this form?
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Including relationship to client
Contact number of person completing this form.
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How will the client be funding services?
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Please Select
Out of Home Care or Insurance
Private Health Fund
Privately paying
Medicare Plan (CDM/EPC)
Goals for Therapy
Can you tell us why your child has been referred for OT?
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What would be the top priority for our OT's to support your child with?
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Child's Medical History
Diagnosis
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Any relevant medical history/allergies
Custody/Guardianship
Child lives with
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Please Select
Both parents
Shared custody
Parent 1
Parent 2
Other
If other, please specify
Is a parenting or restraint order applicable? Eg. Guardianship
Please list any other special family circumstances of which Excel OT should be aware of to provide maximum support.
Please provide the names and contact details of other adults who may be involved in therapy.
For example, grandparents or support workers dropping client off to therapy sessions
Date form completed
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Day
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Month
Year
Date
Submit
Should be Empty: