Excel OT New Client Intake Form

Private/ Medicare Waitlist Submission Excel OT

This form is for clients who are privately funded or using Medicare rebates to fund services.
We understand that accessing occupational therapy services in our region has been extremely difficult. As a service committed to meeting the needs of hundreds of children and families in the area, we are doing our utmost to provide timely and effective support. To help address this demand, we are excited to introduce a new service offering designed to provide a comprehensive starting point for your child’s therapy journey.

About Our New Service Offering

Our inital therapy package is designed to assess your child’s needs and provide you with actionable strategies and recommendations. For all new clients, we will use this package as a starting point.

This package includes:

First session- Initial Consultation (1.5 hours):
An in-depth interview with parents to gather detailed information about the child’s history, challenges, and specific needs.

Second Session- Assessment and Observation Session (1 hour):
The OT will either meet the child directly or conduct structured assessments with parents and carers to understand the child’s functional abilities, current strengths and challenges, and sensory preferences.

Summary Report (allow up to 1.5 hours):
A personalized report will be prepared, tailored to the child and families needs. This could include:
-Support an NDIS application.
-Provide strategies and recommendations for school.
-Offer a sensory summary with recommendations.
-Create a one-page profile of the child.

The report’s type and purpose will be established during the initial sessions.

Third Session- Strategy Meeting (1 hour):
A follow-up session to discuss the report in detail, answer any questions, and plan the next steps, ensuring you feel confident in supporting your child.

Next Steps:
This can be discussed with your OT following the completion of the initial therapy package.

Total Service Duration: 5 hours at $193.99 per hour
Total Cost: $969.95
What we can offer.
If your child or family could benefit from our Get Started therapy package please complete the following:
Clients Name*

First NameLast Name
Client's DOB*
Gender*
Female/male/other
Client's School/workplace and year level*
Parent/Carer Name #1*

First NameLast Name
Parent/Carer Name #2

First NameLast Name
Do any other family members currently or have previously accessed OT with Excel?*
Please provide details if possible
Home address*
Email Address*
Phone Number*
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? *
Including relationship to client
Contact number of person completing this form. *
How will the client be funding services?*
Goals for Therapy
Can you tell us why your child has been referred for OT?*
What would be the top priority for our OT's to support your child with? *
Child's Medical History
Diagnosis*
Any relevant medical history/allergies
Custody/Guardianship
Child lives with*
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

DayMonthYear
Date
Should be Empty:

Private/ Medicare Waitlist Submission Excel OT

What we can offer.

If your child or family could benefit from our Get Started therapy package please complete the following:

Goals for Therapy

Child's Medical History

Custody/Guardianship