Allied Health - Expression of Interest
Penrith Childcare Services are taking expressions of interest for Behavioural Therapy Services.
Did you know that Penrith Childcare Services already provide Speech Therapy and Occupational Therapy services?
Parent's full name
*
Child's full name
*
Child's Date of Birth
*
/
Day
/
Month
Year
Date
Address
*
Street Address
Suburb
State
Postcode
Contact number
*
Email
*
example@example.com
Current Concerns
Daily activities and routines
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Eating
Putting on shoes
Putting on socks
Focusing on learning
Writing
Playing with toys
Playing with other children
Sharing
Taking turns
Develop confidence with daily activity
Communication
Following instructions
Expressive language
Receptive language
Funding Details
Plan Management type
*
Self-Managed Plan NDIS
Plan Managed NDIS
Private Health Care
Medicare
Other
Do you have a referral?
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Yes
No
Do you require an interpreter?
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Yes
No
Does your child currently attend any early education and care services or school?
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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 unexpectedly, self-injury, seizures, severe allergies or other concerns.
*
No
Yes
If yes, please provide brief details
Please attach any reports, referrals, or other relevant documents
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