Please note: we are only taking referrals for Occupational Therapy Assessments and Functional Capacity Assessments

Child's name: *

Child's DOB: *

Gender: *

Person Making Referral Name: *

Relationship To Child *

Email Address *

Phone Number: *

Preferred contact method: *

EmailPhone callText message

Address: *

Child's school, suburb and class: *

Diagnosis: *

What are your concerns *

Funding:

NDIS Plan Number:

NDIS Plan Dates:

Please provide a summary or copy of your child's NDIS goals

If PLAN MANAGED - Who is your nominated plan manager?

Reports, Letters etc..

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

Are there any court orders or parenting arrangements we need to aware of? Does the client have any allergies, chronic illness or medical issues we need to be aware of?Are there any concerns with having to wait in a busy waiting room?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?Does the client have any concerns surrounding the child's eating/swallowing/ limited diet?Does the client have anaphylaxis or asthma - please upload management plan

Please tell us more if you have ticked yes to any of the above:

Anaphylaxis/Asthma management plan:

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Please select your preferred clinic *

Functional Capacity Assessment - BelmontOccupational Therapy Assessment and Report - BelmontFunctional Capacity Assessment - TuggerahOccupational Therapy Assessment and Report - Tuggerah

Day/Time preference *

Thursday Friday

What is the purpose of the assessment? *

Has this child or a sibling previously accessed services at Sensational Start OT? *

How did you hear about us?