Happy Dots INTAKE Form

Therapy Services Intake Form

CLIENT INFORMATION

* required field

Legal First Name: *

Legal Last Name *

Preferred Name:

Date of Birth: *

Do you have any religious requirements that we need to know? If yes, please provide details below.

Do you have any cultural requirements that we need to know? If yes, please provide details below.

Does you child have any allergies? If so, please list:

CONTACT DETAILS

Street address: *

Suburb: *

State: *

Postcode: *

Home Phone: *

Mobile: *

Email Address: *

FAMILY/CARER INFORMATION

Caregiver/s Name: *

Relationship to Child: *

Please list who lives in the household with your child, include age and relationship to the child.

Preferred Communication: *

PhoneEmailPost

Are you in need of physical assistance?

YesNo

If yes, please specify your needs below:

Do you/the child speak a language other than English at home? *

YesNo

If yes, please list secondary language/s:

Are you in need of an interpreter? *

YesNo

Do you or your child identify as Aboriginal and/or Torres Strait Islander? *

YesNoPrefer not to say

CLINIC PREFERENCES

Preferred Clinic Location: *

CardiffRaymond TerraceEither

How did you find out about Happy Dots? *

PAYMENT OPTION DETAILS

NDIS

Happy Dots is registered for Allied Health and Therapeutic Supports (0128), we are also able to provide Early Childhood Supports if you are NDIS Plan Managed or Self-Managed.

Are you NDIS Funded?

YesNo

Please provide details if applicable

NDIS Number:

Plan Start Date:

Plan End Date:

How is your NDIS Plan Managed?

Agency ManagedSelf-ManagedPlan Managed

Is your NDIS Plan under ECEI – Early Childhood Supports?

YesNo

Please provide details of you plan management provider if applicable.

Name of Plan Manager:

Phone:

Email:

Please provide details of the coordinator of supports if applicable.

Name of Coordinator of Support:

Phone:

Email:

THIRD PARTY

Is your child funded for services with a third party? (e.g. Wesley, Department of Communities and Justice, Life without Barriers) *

YesNo

Please provide details if applicable

Business Name:

Name of Contact:

Phone:

Email:

PRIVATE HEALTH

Will you be claiming from your Private Health Fund? *

YesNo

Please provide details if applicable

Health Fund Organisation:

Member Number:

MEDICARE

Will you be claiming under Medicare?

YesNo

If yes, please specify below

Chronic Disease Management PlanAutism AustraliaServices for people of Aboriginal or Torres Strait Islander Descent

Cancellation Policy

Happy Dots has a strict 48-hour cancellation and no-show policy. Your appointment time is a contract for the exclusive use of the therapist’s time. A credit card is required at time of booking to secure your appointment. A cancellation fee of $193.99 will be applied to any late cancellations or no show to appointments.

MEDICAL AND DEVELOPMENTAL HISTORY

Does your child have a current diagnosis? If so, please list with dates:

How does your child communicate? *

Single WordsBody language/ gesturesPhrasesFull Sentences

Comments:

SOCIAL HISTORY

In the best interest of your child, we encourage open communication between both parents regarding their therapy services. Sharing information about occupational or speech therapy ensures that both parents are informed about their child’s development and progress. This collaboration helps create a consistent approach at home and in other environments, maximizing the benefits of therapy.

Please note, it is the responsibility of the parents/carers to share information from therapy sessions with each other. Our practice will not facilitate communication between parents or act as an intermediary.

Is there a Behaviour Support Plan in Place?

YesNo

If yes, please provide copies via email to admin@happydots.com.au

Are there any formal custody arrangements and/or court orders in place?

YesNo

If yes, please provide copies via email to admin@happydots.com.au

For parents of children who are separated or divorced, do both parents know the child will be attending Occupational Therapy and /or Speech Pathology services? *

YesNoNot Applicable

Please provide details of any family history which might impact on the child, i.e., divorce, separation, recent moves or family illness.

EDUCATION INFORMATION

School/Education Setting: *

Grade level (where applicable):

Main Contact Person/Teacher: *

Phone Number:

Email:

SERVICE SPECIFIC INFORMATION

Are you seeking Occupational Therapy services? *

YesNo

If yes, please complete the occupational therapy questionnaire below.

OCCUPATIONAL THERAPY

Reminders:

So we can prepare the most appropriate service to your needs, we would like more information about what has brought you to occupational therapy. We also like to reach out to common referrers to offer additional supports.
Please provide any previous reports from other service providers that you think would be helpful.

Has your child seen an occupational therapist before? *

YesNo

If yes, please provide any copies of previous reports and/or assessment results.

REASON FOR REFERRAL

What are the main concerns regarding your child?

What do you want to achieve for your child by coming to occupational therapy?

Is there anything else you feel we should know to assist supporting you and your child?

AREAS OF CONCERN

Are there any current concerns regarding the following areas addressed by occupational therapy?

Please tick all that apply.

Sensory Processing Skills:

Has more extreme activity levels (e.g., high energy or low energy)Displays sensory overload responses (meltdowns)Displays sensory sensitivities that impact on activitiesDisplays strong sensory preferences that impact on activitiesOther

Additional Comments: Please provide any previous reports from other service providers that you think would be helpful.

Are you seeking Speech Pathology services? *

YesNo

If yes, please complete the speech pathology questionnaire below.

SPEECH PATHOLOGY

Reminders:

So we can prepare the most appropriate service to your needs, we would like more information about what has brought you to speech pathology. We also like to reach out to common referrers to offer additional supports
Please provide any previous reports from other service providers that you think would be helpful.

What are the main concerns regarding the child’s communication?

Is there anything else you feel we should know to assist supporting you and your child?

Does your child require support in the following areas addressed by speech pathology?

Additional Comments: