Intake 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 with the next steps.
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
Are you available for urgent assessments in case of last minute cancellations
*
Yes
No
Would you be interested in Telehealth services?
*
Yes
No
What are your main concerns for your child?
*
Is your child speaking/non speaking?
*
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
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