Client Information Form

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We require parental consent for a referral to be made on a child's behalf.

Email *

Your Name (parent/guardian) *

Your Phone Number *

Your Relationship to Child *

Parent

Carer / Guardian

Medical Professional

Plan Manager

Local Area Coordinator

Other:

Child's Date of Birth *

YYYY

Parent/Carer #1 *

Name of first parent/carer

Parent/Carer #2

Name of second parent/carer

Child's Street Address *

Child's Name *

Child's Suburb *

What is your child's diagnosis?
Who made this diagnosis and when? *

How did you find us - or who referred you to us?

Reason for referral *

Details of other therapy your child participates in

To ensure everyone's safety, please answer the following questions: *

Are there any court orders or parenting arrangements we need to be aware of?

Does the client have any allergies, chronic illness or medical issues we need to be aware of?

Does the client have any sensitivities or dislikes we need to be aware of?

Does the client have difficulty finishing or leaving appointments?

Does the client ever abscond (run away) or wander?

Does the client present with unexpected aggressive or violent behaviours?

Other:

Required

Funding Source *

NDIS: Plan Managed

NDIS: Self Managed

Medicare

Self funded

Other:

Required

What days and times are you available for an appointment?

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