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Koala Kids Application Form
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Clients Name
*
First
Last
Preferred Name
If any
Date of Birth
*
dd/mm/yyyy
Gender
Client's Diagnosis
*
Brief Description
Goals for Therapy
*
e.g. sensory processing, emotional regulation, executive function, gross motor skills etc
Suburb for Therapy
*
Contact Name (For organising appointment)
*
First
Last
Phone
*
Email
*
Preferred Day
*
Monday
Tuesday
Wednesday
Friday
Saturday
Preferred Time
*
AM
PM
Preferred Location
*
Home
School
Kinder
Other
NDIS Plan?
*
Yes
No
How is your NDIS plan managed?
*
Self managed
Plan managed
Does the client have any aggressive or violent behaviours
*
Yes
No
Does the client ever abscond (run-away)?
*
Yes
No
Does the client have any allergies or medical conditions (e.g. seizures) we need to be aware of?
*
Yes
No
Is there anything in or around your house that could be dangerous or unsafe for the therapist? (e.g. firearms, animals)
*
Yes
No
If yes, please list what the hazards are
Confirmation
*
I acknowledge that upon submitting this form, I will be contacted by Koala Kids for further discussion when an appointment becomes available.
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