Wagga OT Intake Form

Intake Form

Wagga Occupational Therapy - ABN 61 684 083 574
Please note: Wagga Occupational Therapy currently only accepts referrals for clients accessing services through the NDIS or Home Care Packages. At this time, we are unable to accept private clients or referrals outside of these. If you have any questions or concerns, please do not hesitate to get in touch.
Participant Information
Participant Full Name
Participant Preferred Name
Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Gender

Other
Participant Address
Is the participant living in SIL Housing
SIL Housing details
Participant Phone number - if none type NA
Participant Email Address
example@example.com
Preferred Method of Contact
NDIS Plan Information
NDIS number
Plan Start Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Plan End Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Please upload a copy of the NDIS plan

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Does the Plan includes funding periods?
Funding periods and available funds
Total funding for therapy supports
Funds confirmed as available and allocated to Wagga OT
Current supports participant is accessing

Other
Is the participant Plan Managed or Self-Managed?
Please Provide Plan Manager Name and Email address if none type NA
Do you have a Support Coordinator?
Support Coordinator Name and Email address - if none type NA
Therapy Supports
What type of service are you requiring?

Other
Primary Reason for referral
Top 3 Therapy Goals - if none type NA
Where are sessions to be held

Other
If Outside Wagga are you willing to travel to Wagga Wagga

Other
Telehealth Acceptable
Available Days for Support
Diagnosis, Medical and Safety Information
Formal Diagnosis
Diagnosis Details - please provide a copy any reports
Please upload any relevant medical or allied health reports (pediatrician, psychologist, previous occupational therapy assessments, speech pathology)

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Do you have a Current Care Plans - If Yes please provide a copy
Please upload any relevant Current Care Plans

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Do you have a Current Behavior Support Plan - If Yes please provide a copy
Please upload any relevant Current Behavior Support Plan

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Other Notes or Important Information
Referral Information

Other
Primary Contact:
Name
Relationship
Phone number
Email
Address
Primary Decision Maker / Authorised Consent Person:
Name
Relationship
Phone number
Email
Address
Name
Relationship
Phone number
Email
Address
Next of Kin/Emergency Contact:
Name
Relationship
Phone number
Email
Address
Who should we send any forms and service agreements to be completed or signed to?

Other
Who should we contact to arrange appointments?

Other
Will a support worker attend the sessions?

Other
Support Worker organisation details
If this is a self referral, I give permission Aus Disability Support to share relevant reports, information and updates with:
If self referral, I consent to Aus Disability Support Pty Ltd collecting and storing my personal and medical information for the purpose of providing allied health services. I understand my information will be kept confidential and only shared with relevant professionals involved in my care as required.
Signature of person completing the form
Name of person completing the form
Relationship to client - if self, type NA
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Version: 1

Last updated: 07/09/26
Should be Empty:

Intake Form

Participant Information

NDIS Plan Information

Therapy Supports

Diagnosis, Medical and Safety Information

Version: 1