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NEW CLIENT INTAKE FORM

Parent/s or Caregivers Details

Full name*

Relationship*

Phone*

Email*

Clients Details

Name*

Last name*

Address*

Child's DOB*

Day

Month

Year

Gender*

Female

Male

Other

Education

Attends school or child care*

School or Child Care Name

Grade

Medical

Does your child have any formal diagnosis?*

Does your child have any suspected diagnosis?*

Any further relevant Medical information, or concerns the OT should be aware of?

Occupational Therapy

Preferred Location of Sessions*

School

Home

Other

Preferred Frequency of sessions*

Weekly

Fortnightly

Bi-weekly

Please select your preferred day/s for sessions.*

Monday

Tuesday

Wednesday

Thursday

Friday

Please select all applicable.

Preferred time*

Morning

Midday

Afternoon

Other

Areas of concern*

Gross Motor

Fine Motor

Sensory Processing

Emotional Regulation

Self Care e.g toileting

Social and Play Skills

Cognitive Abilities

Handwriting

Attention and Concentration

Other

Does the child see any other professional/s*

Yes

No

If yes, please select all applicable

Speech Pathologist

Physiotherapist

Psychologist

Paediatrician

Behavioural Therapist

Other

Funding Options

Please select funding type*

NDIS

Private Paying

EPC Plan (Medicare)

Other

NDIS fund management

NDIS Number

Upon submitting this form, your personal details will be sent securely to Making Milestones Occupational Therapy. Please review and accept the Privacy Policy of Making Milestones Occupational Therapy.

I have reviewed the privacy policy and I accept.

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We acknowledge The Traditional Owners of Country throughout Australia and recognises the continuing connection to lands, waters and communities. We pay our respect to Aboriginal and Torres Strait Islander cultures; and to Elders past and present.

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