Person Making Referral Name:
Child's school and year:
Child's school address:
National Disability Insurance Scheme- Plan Managed
National Disability Insurance Scheme- Self Managed
National Disability Insurance Scheme- Agency Managed
If you selected other, please outline funding here:
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?
Please tell us more if you have ticked yes to any of the above:
Please select your preferred clinic- please note wait times may vary between locations:
Belmont: Monday - Friday
Tuggerah: Monday - Thursday
Home: Monday - Friday
School: Monday - Friday
Telehealth: online sessions completed in your home/school/community environment
Preferred therapy days and times - please note while preferences will be considered due to our waitlist alternate appointment times may be offered :
How did you hear about us?