Early Childhood & Therapy Support Customer Intake Form
Form Completed By
*
Child's full name
*
Date of Birth
*
Gender
*
Address
*
Street Address
Street Address Line 2
City
State
Postcode
Country of Birth
*
Parent/carers name
*
Address if different to above:
Mobile phone contact for parent/carer
*
-
Area Code
Phone Number
Other phone contact for parent/carer
-
Area Code
Phone Number
Email Address for parent/carer
*
example@example.com
Are you engaged with any other organisations or medical specialists?
Therapy services
Brighter Futures
Sapphire Neighbourhood Service
NSW Department of Communities & Justice (formally FACS)
Family Referral Services
Paeditrician
Other
If possible, please provide the name/s of the medical specialist, therapist, etc that you are working with?
Do you give PlayAbility permission to speak with the organisations or medical specialists that you are currently involved with?
Yes
No
Is your child of Aboriginal or Torres Strait Islander Origin?
*
Yes
No
Is your familiy from a culturally and linguistically diverse (CALD) background?
*
Yes
No
Languages Spoken at home
Do you require an interpreter?
Yes
No
NDIS number
*
NDIS Plan
*
Yes
No
Are there set funding periods in this NDIS Plan
*
Yes
No
NDIS Plan start date
*
NDIS Plan finish date
*
Plan Management
*
Plan Management Agency (an agreement with a provider of Plan management)
Self Managed
NDIA Managed (Providers claim payment directly from the NDIA)
I'm not sure what Plan Management is
If you are Plan Managed please enter name of Plan Management Agency
Plan Management Agency email address
example@example.com
Plan Management Agency contact number
-
Area Code
Phone Number
NDIS plan attached (this is voluntary, it is valuable for us to see the goals you have set for your child in the plan - you can just attach those pages if you prefer)
yes
no
Diagnosis (if applicable), diagnosed by and date:
*
What services are you requesting?
*
What are your main concerns?
Please attach your NDIS plan and all current and relevant reports
Browse Files
Cancel
of
How did you hear about PlayAbility?
Paediatrician
Family Member
Preschool
Friend
Community Health
EACH
Other
Signature
*
Date
*
/
Month
/
Day
Year
Date
Have you remembered to attach your NDIS plan and reports? If you prefer you can email documents to admin@playability.com.au or drop them off in person at either our Bega or Eden office. If you need any assistance please contact us on 02 64961918. After completing this form the child will go on our waitlist for an Initial Consultation with our EI or Therapy Supports manager. You will receive a call or email to organise this appointment.
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