Appointment Enquiry Form

Thank you for your Enquiry

Once this form has been submitted you will receive a confirmation email from us immediately

(Please check Email Box including Junk Email)

In Sync Kids Occupational Therapy needs to collect information about you for the primary purpose of providing a quality service to you. In order to commence this process, we need to collect some personal information from you in this form and may also be by phone. This information will be kept private and confidential.

Please select a preferred clinic location *

ChermsideRosalieEither

PERSONAL DETAILS

Child's First Name *

Child's Last Name. *

Child's Date Of Birth *

Gender *

Male FemaleNon-BinaryPrefer not to say

Home Address

Suburb *

Postcode

Parent 1 Name *

Parent 2 Name

Parent 1 Phone number *

Parent 2 Phone Number

Parent 1 DOB

Parent 2 DOB

Parent 1 Email Address *

Parent 2 Email Address

Are there any Communication, Language or Cultural requirements we need to be aware of. *

Medicare Card Number

Reference Number

Expiry Date

Private or NDIS (Self/Plan Managed) *

NDIS Plan Number

NDIS Plan Manager Details

A $100 payment will be requested at the time of the booking the Initial Assessment.

The payment is part of the full Initial Assessment costs and is non- refundable after booking has been processed. Costs of the Initial Assessment booking will be discussed with you at the time of the phone call and prior to taking payment of the $100.

This amount covers our clinician's either reviewing and triaging the completed referral form, Initial Parent Questionnaire and/or documentation from any other providers prior to the Assessment taking place.

Confirmed Preplanning Payment *

REASON FOR REFERRAL

Describe your child's areas of concern. (Behaviours and Emotions) *

Any other specialists or allied health professional seen

Is there any other family members attending or previously attended our clinicName of family member and OT

How did you hear about us eg. Other Allied Health Provider, GP, School, Kindy (please provide their details), Google, friend *

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