Personal Details

Payment Option Details: NDIS

Please provide details of you plan management provider if applicable

Payment Option Details: Third Party

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Payment Option Details: Private Health

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Payment Option Details: Medicare

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

Social History

In order for us to best work with you, we need to know a little about your family. If you are unsure how to answer, feel

free to leave those sections for our first session.

Education Information

Reason for Referral

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.

Areas of Concern

Are there any current concerns regarding the following areas addressed by occupational therapy? Please tick all that apply.