Intensive Request Form January 2026

Intensive Request Form January 2026
Caregiver Name*

First NameLast Name
Contact Information
Email*
example@example.com
Phone Number*
Input with no spaces or dashes.
Child's Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

SuburbState

PostcodeCountry
Child's Information
Child's Date of Birth*

MonthDayYear
Child's Gender*

FemaleMaleNonbinaryOther
List any diagnoses your child has:*
List any medications your child currently takes:*

Required Forms
Please complete and upload the Risk Management form from our website:*

Cancelof
Please upload a recent photo of your child (to be stored in their file):*

Cancelof
Has your child been seen at The Sensory Gym before?*

Yes - my child was seen within the past 12 months (after January 2025)Yes - my child was last seen prior to January 2025No
Are you using NDIS funding for this intensive?*

Self-Managed NDISAgency-Managed NDISPlan-Managed NDISNo/none of the above

New Client Info
Please upload your completed Referral Questionnaire:*

Cancelof
Please upload your completed Sensory History Form:*

Cancelof
You may upload any additional documents that are relevant (i.e., therapy reports, etc.):

Cancelof
Funding
Are you using NDIS funding for this intensive?*

Self-Managed NDISAgency-Managed NDISPlan-Managed NDISNo/none of the above

Returning Client Details
Funding
Are you using NDIS funding for this intensive?*

Self-Managed NDISAgency-Managed NDISPlan-Managed NDISNo/none of the above

Funding Information
NDIS Participant Number*
NDIS Plan Start Date*

MonthDayYear
Date
NDIS Plan End Date*

MonthDayYear
Date
Please upload your child's current NDIS plan. If your plan is self-managed, please upload only your child's plan goals. *

Cancelof

Cancellation Policy

If you cancel and we are unable to find a replacement for your spot, the following cancellation fees will be assessed. If these fees are not covered by NDIS you will be liable for these charges. This also includes no-shows and is applicable to all NDIS and non-NDIS clients.

Cancellations less than 20 business days before intensive	$50 cancellation fee
Cancellations less than 10 business days before intensive	Charged 50% of full intensive fee
Cancellations less than 5 business days before intensive	Charged 100% of full intensive fee

NOTE: If any individual sessions are cancelled during the intensive week you will be charged 100% of the fee for that session.

Sign here to indicate you have read and understood the terms of the cancellation policy:*

Clear
Should be Empty:

Intensive Request Form January 2026

Contact Information

Child's Information

Required Forms

New Client Info

Funding

Returning Client Details

Funding

Funding Information

Scheduling Request

Cancellation Policy