Allied Health Expressions of Interest
Penrith Childcare Services are taking expressions of Interest for Occupational Therapy and Speech Therapy services.
Which allied health support service do you require?
*
Occupational Therapy
Speech Therapy
Parents full name
*
Child's full name
*
Child's Date of Birth
*
/
Day
/
Month
Year
Date
Address
*
Street Address
Suburb
State
Postcode
Phone number
*
Email
*
example@example.com
Current Concerns - Speech and Occupational Therapy
Communication:
*
Following Instructions
Expressive language (use of language)
Receptive language (understanding)
Speech sounds
Intelligibility of speech
Spelling
Reading
Writing
Other
Feeding:
*
Excessive pickiness
Restricted intake / refusal
wont eat certain foods or textures
Become distressed if foods touch each other
Difficulty staying seated during meals
Extended meal times
Eating non food items
Sensitive to food smells
Coughing or gagging during meals
Other
Daily activities and routines
Eating
Putting on shoes
Putting on socks
focusing on learning
Writing
Playing with toys
Playing with other children
Balance
Coordination
Develop confidence with daily activity
Other
Funding Details
Plan Management type
*
Self Managed Plan NDIS
Plan Managed NDIS
Private Health Care
Medicare
Other
Do you have a referral
*
Yes
No
Do you require an interpreter
*
Yes
No
Does your child currently attend any early education and care services or school?
*
Yes
No
If yes, which service does your child attend?
Are there any behaviours, medical needs or other concerns that could affect the safety of your child, our staff or other clients during the sessions? This may include aggression, running away unexpectantly, self injury, seizures, severe allergies or other concerns.
No
Yes
If yes, please provide brief details
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