Can my kid access therapy with OT for Kids?

Child’s Name*

Name Family name

Child’s age*

Please enter a number from 0 to 19.

Child’s gender*

Male

Female

Child’s Address*

Street Address City ZIP / Postal Code

(Where the child normally lives)

Child’s confirmed or suspected diagnosis*

Name of Parent*

First Last

(so that we can contact you by name)

Best contact phone number*

Parent’s Email Address*

Language other than English

Yes, I need an interpreter

Please describe or list what you are hoping to work on in occupational therapy*

Which areas of your child’s development concerns you?*

What are your child’s strengths?*

Which services would be of help to you?*

Clinic intervention

School or community visit

Telehealth or online services

Group program

Assessment only

Training and parent information

Which days or times would fit best with your family’s schedule?*

Do you need an after-school appointment time?

Yes

How did you find out about OT for Kids?

Digital (Google or other search, website)

Social media (Facebook)

Word of mouth

Referral from a friend, family or colleague

Referral from Blacktown Speech Pathology Services

Referral from another professional, such as NDIS LAC, paediatrician or your GP

Referral from a school or early childhood centre

Special choice

I would like to be invited to an OT for Kids ‘Cuppa and Chat’ Session.

(These are short, online advice and/or information sessions offered to parents who register via this form.)

Comments

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