Client Intake Form

Thank you for taking time to complete our intake form. This may take 10 minutes to complete.

If you have any questions or would like to provide your information in a different method, please contact Allay Occupational Therapy.

Client Details

Full Name:

First Last

Pronouns:

Date of Birth:

Home Address:

Address City State Post Code

Phone Number:

Email Address:

Preferred Communication Method

Are you Aboriginal or Torres Strait Islander?

Which country were you born in?

Do you need an interpreter to help understand people who speak English?

Which language/s do you speak at home?

Are there ways we can include your culture in OT?

Please attach any past reports or information

Drop files here or

Max. file size: 100 MB.

Goal

Please outline your priority goal to focus on in your brief intervention OT block. The more we can learn about you prior to the first session, the better prepared we can be for our initial assessment.

Goal:

Do you have anything else you would like to receive from your OT:

E.g. an assessment report, an individualised sensory program, visual resources? Please refer to our pricing schedule.

Are there family members or informal supports?

Name:

First Last

Relationship:

Are we able to share any important information with this person?

Contact number:

Email address:

Is there anything important we may need to know before contacting this person?

Are there other family members or informal supports?

Name:

First Last

Relationship:

Are we able to share any important information with this person?

Contact number:

Email address:

Is there anything important we may need to know before contacting this person?

Are there any medical or professional in the support network?

Name:

First Last

Organisation:

Are we able to share any important information with this person?

Contact Number:

Email Address:

Are there any other medical or professionals in the support network?

Name:

First Last

Specialty:

Organisation:

Are we able to share any important information with this person?

Contact Number:

Email Address:

Disability and Health

What is the main health condition or disability?

Are there other health conditions or disabilities?

Are there any allergies?

Life Overview

Tell us a bit about your important people, such as family or friends

Tell us a bit about where you live and your house

Tell us a bit about your work, study, programs, schooling or activities

Are there any things that have happened in your life that may be important for the OT to know?

Client Intake Form

Client Details

Goal

Are there family members or informal supports?

Are there other family members or informal supports?

Are there any medical or professional in the support network?

Are there any other medical or professionals in the support network?

Disability and Health

Life Overview

Terms of Service