Excel Occupational Therapy Waitlist Submission

If you would like to be on our occupational therapy waitlist please complete the following form and we will be in touch when we have availability.

Child's first name *

Child's last name *

Child's DOB *

Parent/Carer Name *

Parent/ Carer last name *

Email address *

Phone number *

Home address *

Who is completing this form?

Person's name completing form *

Relationship to client? *

Who do we contact to organise services? *

Contact number *

OT services required

Please note that during this time we are ONLY accepting referrals for ongoing NDIS funded clients and any client who might require assessment. Currently our waitlist for private and Medicare funded clients in closed for ongoing therapy due to more than 12 months wait time.

What service do you require? *

Ongoing therapy to support skill development Assessment (Eg. Functional Capacity Assessment, Sensory Assessment, Handwriting Assessment)

Please comment on the type of assessment you require if known

Funding infomation

How will OT services be funded *

NDIS participantPrivate/ Medicare

Please note we are only accepting NDIS funded participants FOR ONGOING THERAPY during this round of intakes to our waitlist. We are accepting referrals for ALL clients for ASSESSMENT ONLY.

What is your NDIS participant number?

How is your NDIS plan managed?

Self managed Plan managed

If PLAN MANAGED who is your plan manager?

Parent/Caregiver Questionnaire

Child information

The information provided in this questionnaire is important in determining the most appropriateassessment and intervention for your child. Your careful consideration is appreciated and expected. If youare unsure, please indicate in the space provided. Thank you for your assistance

First Name

Last Name

Preferred Name

ATSI

AboriginalTorres Strait IslanderNone of the Above

Date of Birth

Gender

Language spoken at home (if English is a second language)

Family Infomation

Parent/Caregiver Name 1

Parent/Caregiver Name 2

Caregiver 1 Occupation

Caregiver 2 Occupation

Is there any shared care or court orders in place? Please provide details

Is there any family history of developmental delays, mental illness or other relevant conditions?

Are there any religious or cultural practices your family observes that you would like us to know about?

Who else lives in the home?Please provide names and ages

Child's Medical History

Diagnosis:

Medication:

Has vision and hearing recently been tested?

Any relevant medical history?

Any allergies?

Current Professional Involvement

GP:

Paediatrician:

Pyschologist:

Behavioural Therapist:

OT:

Physio:

Speech Pathologist

Tutor:

Other:

Developmental History

PregnancyLength? Complications?

BirthComplications?

Disposition as a baby:

Age began crawling:

Age began walking:

Age talking so others could understand:

Preschool/School information

School Name:

Year Level:

Teacher name:

Child's strengths and interests at school:

Has your child's teacher identified any concerns?

Does your child like school?

Yes No

Functional Performance

Dressing themselves:Is your child completing this task independently, requires assistance, able to complete zippers, buttons or refuses to complete this task

Washing themselves:Is your child completing this task independently, requires assistance, dislikes the activity etc

Washing or brushing their hair:Is your child completing this task independently, requires assistance, dislikes the activity etc

Eating - DrinkingIs your child eating a variety of foods, using cutlery etc

Brushing teeth:Is your child completing this task independently, requires assistance, dislikes the activity etc

Toileting:Is your child independent with toileting, requires assistance, requires prompting, not yet toilet trained, are they aware when they do a wee or poo?

Sleeping:Does your child sleep in their own bed, require patting/assistance/medication to get to sleep, have disturbed sleep, cosleep etc

Motor performance

Does your child have difficuly learning motor skills:Are they riding a bike? Do they need trainer wheels? Can they learn new tasks like a dance or a trick.

Is you child clumsy or accident-prone:

Can your child run/jump/climb/catch balls to the same level as their peers:

Do you have any specific motor perfomance concerns or things your child really wants to learn how to do?:

Is your child able to open packets or lids independently?:

Is your child able to use scissors independently:

How does your child complete colouring activities:Colouring within the lines most of the time, making some colour within lines, scribbling on page...

Is you child able to complete handwriting to the expected level of their peers:No concern, messy handwriting, poor spelling, poor letter/number formation.

Sensory Processing

TouchDoesn't like particular textures of clothing, doesn't like hair/teeth being brushed, doesn't like dirty hands, touches everything

HearingReacts poorly to loud or unexpected noise, Gets easily distracted in noisy environments, Doesn't respond when you call their name

TasteAvoids particular tastes or flavours. Notices all changes made to meals that you make

VisionGets distracted in visually busy environments, gets upset if you move their toys or change their room, is sensitive to light.

MovementSeeks lots of movement input, can't sit still, dislikes swinging...

Do you have concerns surrounding the following:

Play

Child's interests:

How does your child like to play?

Does you child have friends?

Goals for Therapy

What do you hope to achieve by attending OT? *

If you could pick 3 things to work on in OT what would they be?

Home Visit Risk Assessment

As part of our service we may complete a home visit. We would appreciate if you could please complete the following questions for our therapists:.

Are there any particular religious or cultural sensitivites our team need to be aware of when visiting your home? *

Is there any difficulty finding the property? *

Where would you like our staff to park when attending your home? *

Is there mobile phone reception in your area? *

Are there any pets in your home? *

Who else may be present if we complete a home visit? *

Are there any weapons or fire arms in the house? What sort of weapons? Are they secure? *

Is there any known substance abuse among occupants or visitors? *

Does you child or anyone else in the house have a history of aggressive or violent behaviour? *

Excel Occupational Therapy is committed to ensuring our client and therapist safety.

We respectfully request that no one smoke, or use any unprescribed substances while our team members are completing a home visit.

If your circumstances change and you are unable to ensure our team's safety please let us know as soon as possible.

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