Sense Therapies Intake & Waitlist Form - OT, Speech Therapy & Art Therapy

Type of Therapy *

Occupational Therapy - $226.31 per appt - ($452.62 Initial appt)Speech Therapy - $226.31 per appt - ($452.62 Initial appt)Art Therapy - $226.31 per appt - ($452.62 Initial appt)

How did you hear about Sense Therapies? *

Participant's Availability *

Any time / FlexibleBefore or After School Only (can incur prolonged wait period)Both

Participant First Name *

Participant Surname *

Participant D.O.B *

Pronouns

Address *

Street address *

City *

State *

Postcode *

PRIMARY Carer/Guardian (Full Name) *

PRIMARY Contact Relationship to Participant *

PRIMARY Contact Email Address *

PRIMARY Contact Mobile Number *

Secondary Contact (Full Name) *

Secondary Contact - Relationship to the Participant *

Secondary Contact Email Address *

Secondary Contact Mobile *

What are the Participant's goals in relation to therapy *Attach copy of current NDIS Plan - if applicable (optional) - see end of this form

What would you like the Participant gain from partaking in therapy? e.g. socialisation, gross motor, emotional regulation, sensory processing skills etc *

Do we need to be aware of any risks? e.g. allergies, seizures, triggers etc *

Please specify any diagnoses, pre-existing &/or new injuries we need to consider in how we plan the sessions *

Is there anything the Participant would prefer NOT to partake in? *

Please attach any relevant documentation or reports.

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Payments *

NDIS Plan ManagedNDIS Self Managed Plan - 100% Payable on the dayPrivate Health Insurance - 100% Payable on the daySelf Funded/Out of Pocket - 100% Payable on the day

Primary Carer/Guardian Signature *

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Date of Submission *