Intake Form

Welcome

This form will take about 10-15 min to complete. We will endeavour to contact you as soon as possible to arrange your services.

What services do you require from us?(Required)

Occupational Therapy

Speech Pathology

Participant Details

First Name(Required)

Middle Name

Last Name(Required)

Preferred Name (if different from above)

Date of Birth(Required)

Gender(Required)

Does the client identify as an Aboriginal or Torres Strait Islander?(Required)

Address(Required)

Street Address Address Line 2 City State Zip Code

Language(s) spoken at home?(Required)

Preferred Language(Required)

Interpreter Required?(Required)

Primary Contact Person(Required)

We will contact this person to organise our services

Primary Contact Person's Relationship with the Client ?(Required)

Primary Contact Phone Number(Required)

Alternative Contact Number

Email Address(Required)

We will use this email for all correspondance

School Name (if applicable)

Requested Service Details

Key Diagnosis / Relevant Medical History(Required)

Key Goals(Required)

Any behaviours of concern?(Required)

At times when some clients are upset/ frustrated/ or unable to communicate their needs, they can exhibit behaviours of concern. Identifying these behaviours of concerns will help our therapist to help the client better. Please tick any behaviour of concern that you can identify with the client.

Any trigger(s) for the above behaviours of concern? (if applicable)(Required)

Triggers can include mention of specific words, phrases, a particular toy or action. Please list in as much detail as possible:

Preferred Therapy Location(Required)

Select one or multiple based on your preference.

FunLab Therapy Clinic (Bundoora)

FunLab Therapy Clinic (Eastern Suburbs)

Home

School/Kinder/Childcare

Telehealth

Home Assessment

Home based therapy sessions may be beneficial at points during your child’s intervention. Parents and carers are required to remain onsite for home sessions, to maximise the value of home sessions and transference of therapeutic recommendations. When delivering therapy at your home, we require the room to be clean and clutter free. The room should also be equipped with heating/cooling, should be well ventilated and should be adequately lighted. Please refrain from smoking during the session. Please fill out the following information to prepare our team members appropriately.

Is there adequate on street parking close to the home? (minimum 1 hour parking)(Required)

Do you have pets?(Required)

Can our therapist be exposed to any of the following risks?(Required)

Verbal aggression from any occupants

Physical aggression from any occupants

No potential risk

Other

Other potential risks(Required)

Are there any firearms on the property?(Required)

Any other information regarding the home setup?(Required)

Information about the access, security etc.

Any additional information that you want to provide us?(Required)

Fun Lab Therapy reserve the right to deny home treatment sessions should there pose a risk to our staff.

Funding Details

Funding Source(Required)

NDIS Details

Do you have a copy of your NDIS plan to upload?(Required)

If you are not comfortable to share the whole plan with the budget, you can only send the first 3 pages which are the GOALS section.

Yes

Upload a copy of your NDIS plan(Required)

Max. file size: 128 MB.

NDIS Number(Required)

Plan Start Date(Required)

Plan End Date(Required)

Funding amount available to access required services?(Required)

The number of hours/sessions allocated for therapy(Required)

Normally we can do 26 hours for the 12 months NDIS plan. If you want less hours or the funding allocated is less than that, please specify.

NDIS Funds Managed by(Required)

Plan Manager Details

Plan Manager Organisation(Required)

Plan Manager Contact Person(Required)

Plan Manager Contact Number(Required)

Plan Manager Email(Required)

Medicare Details

Do you have a copy of your Medicare plan to upload?(Required)

Yes

Upload a copy of your Medicare plan(Required)

Max. file size: 128 MB.

Medicare Number(Required)

Medicare Card Reference Number(Required)

Medicare Card Expiry Date(Required)

What Medicare plan do you have?(Required)

Better Access to Mental Health

Chronic Disease Management Plan / EPC

Helping Children with Autism Medicare Plan

Better Start for Children with Disability

Allied Health Services For Indigenous Australians Who Have Had A Health Check

Referral Name(Required)

Referral Provider Number(Required)

Plan Start Date(Required)

Number of Sessions(Required)

Health Insurance Details

Please type your insurance provider(Required)

How did you hear about us?

How did you hear about us?(Required)

Karista Website

Support Coordinator

Allied Health

Family / Friend

Google / Facebook