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
*
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
Please do not fill this form in if you are awaiting funding and are not ready to commence services.
If you are Plan Managed, what is your Plan Managers contact details?
What is your NDIS number?
Thank you!
Thank you for completing our Intake Form.
We will process your intake form and contact you on updates on wait times.
If you are funded by NDIS (Self-Managed or Plan-Managed) here are a few more things to consider:
1:Please have your current NDIS Plan and Goals ready to send to us.
2:We will always prefer an assessment booking in a first initial consultation, unless you have had a previous one completed within 2 years.
3: During this initial consultation we will also elaborate on your child's NDIS goals and discuss any other relevant reports.
Thank you again for completing our intake form.
We will be sure to contact you.
