OCCUPATIONAL THERAPY NEW THERAPY FORM

CONTACT DETAILS

Carer/s full name

Contact Number/s

Home Address

Email

PERSON RECIEVING THERAPY DETAILS

Client’s Full Name

Gender

Date of Birth

Age

School

Name and number of siblings

Current living situation and any family notes to consider

Allergies

Medications

Main challenges for referral to Occupational Therapy?

Please list any previous or current medical conditions or diagnosis (ASD, ADHD...) :

Other (the more information the better):

Has the person been tested in the areas below:

VisionHearingNeurology

Name of therapy provider where they were being seen and any outcomes/results from testing:

Have any sudden changes occurred in the person’s life over the last 12 months?

Are there any risks we may have to consider in the home? (consider escalated behaviour, weapons, reception, dogs etc)

How does the person communicate? (consider verbal or other, use of an AAC device, age appropriate or delays, understanding/receptive language skills)

Does the person have significant postural or mobility issues or does the person use a wheelchair for their day to day activities?

Yes NoWheelchair only for long distances

THERAPY ORGANISATION

Preferred location of therapy? (Home / School / Either / Other)

Are there any days/times you CANNOT do therapy? (ie. Fridays basketball afterschool)

Are there any days/times you PREFER to have therapy? (ie. home all day Thursdays and preferrred)

Are there any specific therapy goals decided upon? (consider NDIS goals also)

Funding scheme

PrivateNDIS Self managedNDIS Plan ManagedNDIS Agency Managed

NDIS Number (If applicable)

Plan Manager’s name/details (if applicable) - invoice email address

NDIS Support Coordinator name/details (if applicable)

Do you give permission for us to email you?

YesNo

Who can we thank for recommending you?