Lil Peeps OT For Kids Referral Form and Service Agreement
The information you provide in this form is confidential, and it provides Lil Peeps with essential information about your child that can assist in providing an Occupational Therapy Service.  We are currently taking referrals for our waitlist for children 3 -12 years. Once your referral is received our administration team will be in contact with you, within 5 business days. 

## Please note we are not accepting referrals for children entering high school, or current high school students.
 
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Email *
Child's Name *
Date of Birth *
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Address
Gender
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Does your child have a diagnosis from a paediatrician, or in the process of receiving a diagnosis? If so please detail:
Are you accessing funding from NDIS? (please note we only provide support to families who self manage or plan manage their funding. Lil Peeps OT is not a registered NDIS provider.) 
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Are you currently applying for funding from NDIS? (please note we only provide support to families who self manage or plan manage their funding. Lil Peeps OT is not a registered NDIS provider.) 
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School Attending *
Parent / Guardian Name *
Parent / Guardian Phone Number *
Year level at school  *
Days attending school
Teacher's Name
Teacher's Email Address
Developmental and medical history - please detail any history relating to the development of your child or their medical needs you think may be relevant to the assessment or therapy process.
Have you accessed OT support previously?
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What are the main areas you are currently seeking support for?
Do you know which assessment option you would like to commence with? *
Required
As a school based provider information regarding your child's assessment, engagement in therapy and their response to intervention is shared with the school. This includes weekly session notes and reports. 
Please indicate which additional agencies you give authority for information​ to be shared with
 *
Required
Are there any family court orders in place that Lil' Peeps needs to be aware of? *
Do you consent to photos being taken of your child for the benefit of the therapeutic process? (these will not be used for marketing purposes)
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Service Agreement 
​I consent to my child having a​n​ Occupational Therapy assessment and therapy by a Lil' Peeps OT for Kids therapist or assistant.
I understand that this is a private billing practice and I will be required to pay within seven days of receiving an invoice. A travel fee will apply for the service. A deposit payment is required before assessment bookings can be made.  (Administration fees are charged for late payment and debt collection services may also be utilised).

By consenting to the above, you are agreeing to our service terms and conditions as detailed in these policies and procedures. https://www.lil-peeps.com.au/_files/ugd/29b9ce_b598982754484ec0a39663d20106e01e.pdf  
 *
Required
A copy of your responses will be emailed to the address you provided.
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