Sense Therapies Kiama: Occupational Therapy Intake & Waitlist Form

Important Accessibility Note (Kiama Clinic)

We want to ensure your visit to our Kiama clinic is as comfortable as possible. Please be aware that our therapy room at the Kiama location are situated on the first floor and are accessed via one flight of stairs.

Please note that we do not currently have lift access at this location. If stairs present an accessibility challenge for your child or a member of your family, please let our administration team know so we can discuss alternative support options or community-based appointments.

Type of Therapy - Initial Parent/Caregiver Appointments: $452.62 *

How did you hear about Sense Therapies? *

Participant's Availability - select all that apply *

Any time / FlexibleBefore or After School Only (can incur prolonged wait period)BothAvailable between 10am and 1:30pmI'm interested in a school/daycare/community appointment (pending school/daycare approval)

Participant First Name *

Participant Surname *

Participant D.O.B *

Pronouns

Participant's School/Daycare *

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

Name of Person Submitting this Form *

Contact Phone Number of Person Submitting this form *

Signature of Person Submitting this Form *

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Date of Submission *