Intake Form

Name

Preferred Name

D.O.B.

Country of Birth

Gender

Male Female Non-Binary Other

Address

NOK P/C

Emergency Contact

Phone

E-mail

Yes Is client of Aboriginal descent No Is client of Aboriginal descent

Yes Is client of Torres Strait Islander descent No Is client of Torres Strait Islander descent

NDIS Plan SELF-MANAGED Plan Manager

Payment will be made by

Phone

E-mail

List the main diagnosis and co-occurring conditions presented by the client

List the main goal you would like this therapy to focus on

Is the client currently taking any medication?

Yes Taking any medication No Taking any medication

If yes list the medication and describe what they are for

Does the client have any challenging behaviours you would like us to focus on? (e.g., aggression, screaming, self-harming, etc.)?

Yes No

If yes, please describe:

Has a behaviour management plan been developed?*

Yes No

f yes, please attach plan:

Is the client currently receiving any intervention or support (e.g., Speech Pathology, OT, etc?)

Yes No

If yes, please provide previous reports

Contact