Neuro - Habilitation Intake and Goals Form

Enrolment, Intake & Consent Form

Kia Kaha Neuro - Habilitation Foundation
Privacy notice

Kia Kaha Neuro - Habilitation Foundation collects the information on this form to plan safe and suitable movement sessions for your child, to contact you, to invoice you or your funder, and, without identifying details, to report to funders. Health information is seen only by the people who need it to support your child. With your consent we may share it with your child's doctor, school, other therapists and funding host. This form is stored with Jotform, which keeps data on servers outside New Zealand, and we keep records for 10 years. You can ask to see or correct your child's information at any time at dora@kiakahafoundation.org.nz.
I have read the privacy notice.
Parent/Caregiver Name

First NameLast Name
Phone Number
Format: 000 000 0000.
Email
example@example.com
Additional Parent/Caregiver Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: 000 000 0000.
Address

Street Address

Street Address Line 2

CitySuburb or town

Postcode
Child's Details

First NameLast Name
Date of Birth

DayMonthYear
Gender
Tell us about your Child.
What are some of the cool things your child is good at?
What activities does your child love to do? What motivates your child?
Medical History

Primary DiagnosisOther
Date of Diagnosis

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Additional Diagnoses/ Diagnosis Description
My child's diagnosis is considered a progressive or degenerative condition.
My child presents with fatigue concerns
Emergency and support contacts
Emergency contact name and relationship
Emergency contact phone
Please enter a valid phone number.Format: 000 000 0000.
GP name and clinic
Specialist or other practitioner name and contact
Current medications and doses
School or early learning centre
People authorised to collect my child, with phone numbers
How does your child show pain or distress?
Ethnicity and iwi
We ask this for funder reporting. You can skip it.
History of medical and/or surgical procedures (please list with dates):
If applicable
History of major hospitalisations (please list with dates):
If applicable
Current weight (in kg)
Current height (in cm)
Does your child have known allergies?
List allergies and detail allergy management plan:
Does your child have a history of or current seizures? *
Are your child's seizures controlled?
What might trigger your child's seizure(s)?
How long do your child's seizures typically last?
Describe seizure type(s) and detail seizure management plan:
Does your child have a history of or current heart problems/hypertension?
Has your child now or ever had a diagnosis of decreased bone density?
Are your child's hips regularly monitored?

Other
Any history of hip subluxation/dislocation?
Medical & Safety Flags
Does the child have any of the following movement session considerations?
No Formal Medical Diagnosis Required

At Kia Kaha Foundation, an official diagnosis is never required to receive support. Whether your child has a formal diagnosis, is waiting for a hospital or specialist assessment, or has an undiagnosed developmental delay, our focus is entirely on functional strengths, movement potential, and what matters most to your whānau.
Communication, Speech & Expression Goals (Optional)
Tell us how your child currently communicates and any specific goals you have (Optional)
Developmental Skills
I would like my child to work on gross motor skills.

Gross Motor Skills

Rows	With an assistive device	With a lot of help	With a little help	Independently
Hold their head steady
Roll
Reach
Sit
Crawl
Pull to stand
Stand
Cruise
Take steps
Walk
Run, Jump, Hop

Gross Motor Comments and Goals
Include here which adaptive device your child may use as well as goals you would like to work on.
I would like my child to work on fine motor, play, and/or self-help skills.

Fine Motor/Activity of Daily Living Skills:

Rows	With only one hand	With a lot of help	With a little help	Independently
Hold object with both hands.
Hold objects functionally.
Brings objects to mouth.
Uses utensils for eating.
Helps with dressing.

Fine Motor/ADL Skills - Comments and Goals
When your child gets upset, what helps calm them down?
Select all that apply.
Tell us about your current support
Funding Pathway & Invoicing
Funding Channel
Client / Portal Reference Number
e.g., Manawanui Client ID, CPSNZ Membership #
Invoice Payee / Budget Manager Contact

First NameLast Name
Invoice Payee / Budget Manager Email
example@example.com
Invoice Payee / Budget Manager Phone
Please enter a valid phone number.Format: 000 000 0000.
Billing, Cancellation & Third-Party Payment Agreement
Fees:

1. Subsidised community bursary: where a place is available, whānau pay $30 per 45-minute session, or $50 for a visiting specialist session.

2. Places are funded by grants and donations, are limited, and are reviewed each School Term.

3. Funding hosts: where sessions are billed to Individualised Funding, Enabling Good Lives or CPSNZ, we send our standard fee invoice to your host.

If funding is exhausted, declined or delayed beyond 30 days, you remain responsible for the fees.

Cancellations: please give 24 hours' notice. Late cancellations and missed sessions may be charged at the scheduled fee, except for acute illness or emergencies.
Movement Consent
I give consent for my child to participate in active movement sessions with Kia Kaha Neuro-Habilitation Foundation. I understand sessions may use specialised suspension systems and positioning equipment.
I agree to these billing terms.
Media & Photography Consent
Media Consent
I consent to Kia Kaha sharing relevant information with my child's doctor, school, other practitioners and funding host, so they can support my child and process invoices.
I consent to my child participating in these active movement sessions.
Authorisation & Signature
Parent / Legal Guardian Full Name
Relationship to Child
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Digital Signature
Should be Empty:

Enrolment, Intake & Consent Form

Emergency and support contacts

Medical & Safety Flags

No Formal Medical Diagnosis Required

Funding Pathway & Invoicing

Billing, Cancellation & Third-Party Payment Agreement

Movement Consent

Media & Photography Consent

Authorisation & Signature