Fill out our
Intake Form to commence your therapy now!

Once we receive this form, our therapy team will
contact you to discuss our pricing and book you in
for assessment, review or therapy sessions.

Guardian 1 Full Name

First Name

Last Name

Guardian 2 Full Name

First Name

Last Name

Contact Email

Phone

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Childs Full Name

First Name

Last Name

Childs Date of Birth

Languages Spoken at Home

What services are you interested in?

To begin therapy we need to investigate your child’s development and decide what is the best course of action. Sometimes this will involve completing a full assessment with us. Other times this will involve us reviewing previous assessments and where required compiling further information for a clear clinical picture to be established so that we can provide comprehensive and effective treatment tailored to your child’s needs and family goals.

What Services are you inquiring about?

These are all the services Zoom Therapy Services offers.

Has your child had any previous Intervention? If yes give details: (name of therapist/service, duration attended, are you currently attending) *

Has your child seen a Paediatrician in the past 12 months? If yes, give details: (name of paediatrician, number of appointments, outcome etc.)

Please email us your child's developmental reports to zoomtherapyservices@gmail.com

What are your main concerns/reasons for wanting to pursue therapy?

Does your child have a diagnosis, illnesses or have had any major accidents?

Do you have any concerns with your child's behaviour? (Behavioural disorganisation, meltdowns, etc)

Are you already engaged in services, do you wish to place your child in social based programs.

How is your therapy funded?

Please note, we will require your NDIS plan emailed to us prior to your first therapy session. Email your NDIS plan to zoomtherapyservices@gmail.com

Plan-Managed (I will provide my Plan Manger's contact details)

Self-Managed (I will provide my NDIS plan)

I don't have NDIS (I am private paying)

I will be using Medicare (I have a CDM / EPC or a Better Access to Psychological Services (Mental Health Plan)

If you are Plan Managed, what is your Plan Managers contact details?

What is your NDIS number?

Fill out our Intake Form to commence your therapy now!

Fill out our
Intake Form to commence your therapy now!