Complete our Intake Form to commence your therapy ASAP.Once we receive this form, our Admin 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 * Do you need a developmental assessment? * To begin therapy we need to investigate your child’s development and decide what is the best course of action. Sometimes this is an informal chat and play based assessment and other times we need to measure your child against developmental norms for diagnosis and goal setting. Speech Pathology Assessment Early Childhood Intervention Functional Assessment Dietetics , Feeding and Nutrition Assessment Multidisciplinary Assessment I would like to discuss what my child needs with a Therapist. I do not need an assessment. What services are you inquiring about? * Speech Pathology (0-15 years) Occupational Therapy Early Intervention (0-9 years) Paediatric Osteopathy Paediatric Exercise Physiology Dietetics, Feeding and Nutrition (0-12 years) Counselling (0-12 years) Allied Health Assistant (Speech Pathology) Parent Counselling 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 office@necessitykids.com.au What are your main concerns/reasons for wanting to pursue therapy? * What medications is your child currently taking? * Do you have any concerns with your child's behaviour? (Violence, meltdowns, etc) * Has your child had their vision tested? If yes - when & what were the results? * Has your child had their hearing tested? If yes - when & what were the results? * Does your child have a diagnosis, illnesses or have had any major accidents? * Please email us your child's developmental reports to office@necessitykids.com.au 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 office@necessitykids.com.au 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). Please note this option is only for Speech Pathology. If you are Plan Managed, what is your Plan Managers contact details? * What is your NDIS number? What school or early learning service does your child attend? * What days does your child attend an early childhood service / school? * Preferred days / times for therapy? * Please note, we will do our best to accomodate your preferred days/times for therapy. Monday Tuesday Wednesday Thursday Friday Any Additional Comments? Thank you for completing our Intake form, Necessity Kids will process your intake form and contact you soon. In the meantime if you have any reports or assessments that will assist us with the intake process please forward them to our operations team on office@necessitykids.com.auFrom the team at Necessity Kids
