New Client Intake Form – Illawara Therapies

About You

What services are you applying for? *

Art Therapy
Early Childhood Supports
Positive Behaviour Practitioner
Massage Therapy

Your Name *

First

Last

Your Email *

Your Phone Number *

Your preferred method of communication for our initial contact *

Phone
Email
By Mail/Letter to my address

What best describes you? *

Participant
Parent/Guardian
Friend or Advocate
Other

The participant is the person who will be receiving the service. This may be you, your child, or another person that you're helping complete the form for. If you are a provider, or support co-ordinator, please use our New Client Referral Form.

How did you hear about Illawarra Therapies?

About the Participant

Funding Type: *

NDIS Plan - Self Managed
NDIS Plan - Plan Managed
NDIS Plan - Agency Managed
Not NDIS - Private Client

Participant's NDIS Details (if on an NDIS plan)

First

Last

If you are on an NDIS Plan, please provide the details above. Skip this step if you are a private client applicant.

Plan Manager Details

First

Middle

Last

If you are on an NDIS Plan, please provide the details above. Skip this step if you are a private client applicant.

Participant's Name *

First

Last

The 'participant' is the person who will be receiving the service. This may be you, your child, or another person you are caring for.

Participant's Date of Birth *

Participant's Home Address *

Languages Spoken at Home *

Do you require an interpreter? *

Yes
No

School or Childcare provider (if under 18)

About the Therapy

Current NDIS Goals (where applicable)

You can provide a copy of the participant's goals by emailing their NDIS Plan to us, or copy and paste the goals from their plan here.

Personal Interests

Let us know more about the participants personal interests.

Strengths

Let us know more about the participants strengths.

Areas for Development

Let us know if there are areas of concerns (such as behaviours, safety etc) where the participant may need help and support when in the community, school or at home?

Current Allied Health Supports

Who do you currently use for services such as Art Therapy, Positive Behaviour Practitioner, Speech Therapy, Occupational Therapy, Exercise/Physio etc?

Former Allied Health Supports

Who did you previously use for services such as Art Therapy, Positive Behaviour Practitioner, Speech Therapy, Occupational Therapy, Exercise/Physio etc?

Medical Needs

Please provide details of any diagnosis, allergies or special medical needs that can assist us in understanding how we can support you with our services.

Outcomes You are Looking For

Please let us know what outcomes you are looking for from Illawarra Therapies services, how can we best support you or the person you are caring for?

Other Comments or Useful Information

Please let us know anything else that can help us support you.

Supporting Documents

Please provide any documentation that will help us plan your therapy goals (where relevant). You can upload the documents here, or email them through to us later.

Current NDIS Plan Goals (required if on an NDIS Plan)
Safety Plan
Behaviour Support Plan
Other relevant Medical or Therapy Reports

To help us understand your needs and to prepare a support plan for the participant, we can use as much information as you're willing to share. If you have reports or plans that will help us prepare for communication, behaviour management and set clear goals for therapy outcomes, please upload these documents below or you can email a copy of these through seperately to info@illawarratherapies.com.au

File Upload

Click or drag files to this area to upload. You can upload up to 10 files.

Allowed file types: .doc, .docx, .pdf, .png, .jpg Maximum file size 20MB