Intake Form

Before completing this form, we want to make sure we have the right Occupational Therapist for you. Call (03) 5201 0527 or email info@allayoccupationaltherapy.com.au to help us understand your needs.

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.

Step 1 of 9

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Participant 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?

Are you completing this form for yourself or on behalf of a relative?

Funding Type

Hidden

Please attach any plans or past reports

Max. file size: 100 MB.

Please attach any plans or past reports

Drop files here or

Max. file size: 100 MB.

Referrer Details

Name

First Last

Relationship to you:

Organisation, if applicable:

Phone

Goals

List which goals to work on with OT.

Goal 1:

Goal 2:

Goal 3:

Hidden

Are there particular areas of focus for OT?

Independent Living Skills

Social Interaction/Relationships

Employment or Study

Accessing the Community

Behaviour Support

Motivation

Sensory Profiling

Cerebral Palsy

Autism Spectrum Disorder

ADHD

Mood - Anxiety, Depression

Mental Health

Early Childhood Intervention

Group Therapy

Fine Motor Skills

Gross Motor Skills

Developmental Milestones

Handwriting

School Skills

Organisational Skills

Animal Assisted Therapies

Are there family members or informal supports?

Name:

First Last

Relationship to you:

Are we able to give any relevant information to this person or organisation?

Are we able to receive any relevant information from this person or organisation?

Contact number:

Email address:

Provide anything important we may need to know before contacting this person.

Are there other family members or informal supports?

Name:

First Last

Relationship to you:

Are we able to give any relevant information to this person or organisation?

Are we able to receive any relevant information from this person or organisation?

Contact number:

Email address:

Provide anything important we may need to know before contacting this person.

Who is the NDIS Support Coordinator?

Name:

First Last

Organisation, if applicable:

Are we able to give any relevant information to this person or organisation?

Are we able to receive any relevant information from this person or organisation?

Contact Number:

Email Address:

Who is the GP (General Practitioner)?

Name:

First Last

Organisation, if applicable:

Are we able to give any relevant information to this person or organisation?

Are we able to receive any relevant information from this person or organisation?

Contact Number:

Email Address:

Is there a professional in the support network?

Name:

First Last

Specialty:

Organisation, if applicable:

Are we able to give any relevant information to this person or organisation?

Are we able to receive any relevant information from this person or organisation?

Contact Number:

Email Address:

Are there any other professionals in the support network?

Name:

First Last

Specialty:

Organisation, if applicable:

Are we able to give any relevant information to this person or organisation?

Are we able to receive any relevant information from this person or organisation?

Contact Number:

Email Address:

Disability and Health

What is the main health condition or disability?

Are there other health conditions or disabilities?

Which disability or disabilities are registered with the NDIS?

Are there any allergies?

Life Overview

Tell us a bit about your family:

Tell us a bit about where you live and the people you live with:

Are you studying or working?

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

Regulatory Overview

Is there involvement with Child Protection?

Describe:

Are there any Court Orders?

Describe:

Are there any Community Interventions?

Describe:

Is there any involvement in the Justice System?

Describe:

Risk Considerations

Are there issues with assault or aggression, past or present?

Describe:

Are there any sexualised behaviours, past or present?

Describe:

Is there any substance use, past or present?

Describe:

Is there any self-injury or suicidality, past or present?

Describe:

Are there any home visit risks?

Describe:

Are there any behaviours of concern?

Describe:

Funding Overview

Participant/Claim Number

Plan Start Date

Plan End Date

Total amount allocated to Allay

Payment Method

Email or Plan Manager for invoices:

Reporting

Any reporting will be finalised before the end of the NDIS Plan year and will be emailed to the NDIS.

Email address to send report to:

Due date for the report: