Sense Therapies Intake & Waitlist Form

Type of Therapy *

Occupational Therapy (OT) - $193.99 per appt - ($387.98 Initial appt)Speech Pathology - $193.99 per appt - ($387.98 Initial appt)Art Therapy - $193.99 per appt - ($387.98 Initial appt)

How did you hear about Sense Therapies? *

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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Funding / Payment Method *

NDIS - Plan ManagedNDIS - Self ManagedPrivate HealthSelf Funded (including Medicare)

Where to email Invoices : Plan Manager OR Participant/Guardian's email *

NDIS Number - ENSURE DETAILS CORRECT & COMPLETE (if applicable) *

NDIS Plan Start Date - ENSURE DETAILS CORRECT & COMPLETE (if applicable) *

NDIS Finish Date - ENSURE DETAILS CORRECT & COMPLETE (if applicable) *

Primary Carer/Guardian Signature *

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Date of Submission *