Waitlist form
Dear Parent, at Kool KATTS we will endeavor to have your child booked in with us as soon as we possibly can. Please complete the below form so that we can contact you as soon as an appointment is available
Child's Name
*
Parent/Caregiver Details
*
First Name
Last Name
Email
*
example@example.com
Contact number
*
Child's date of birth
*
-
Day
-
Month
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you interested in the SENSE RUGBY group only?
*
Yes
No
We occasionally have cancellations and are able to fit in urgent assessments needed. Would you like to be notified when an urgent assessment time is available? **Please note that this is only an assessment and you will need to stay on our waitlist after the assessment for regular appointments**
*
Yes
No
Would you be interested in Telehealth services?
*
Yes
No
What are your main concerns for your child?
*
Is your child verbal/non verbal?
*
Does your child have a diagnosis? If so, please provide more detail.
*
Does your child have any medical conditions?
*
Current Medication
What days are you available?
*
Monday
Tuesday
Wednesday
Thursday
Friday
What are your preferred times?
*
Morning
Midday
After school
Does your child have NDIS funding?
*
Private paying
Self managed NDIS
Plan managed NDIS
NDIA managed (funding is held by NDIS)
Awaiting NDIS funding
School grade/year?
*
What school does your child attend? Are they in a mainstream or support class?
*
What are your goals for therapy
*
How did you hear about us?
*
Our after school appointments are generally offered first to current clients. If your child is at school would you be interested in an appointment time during school hours and offered an after school time asap.
Yes, we need therapy asap
No we can only make after school
Submit
Office Use Only
Direct
Should be Empty: