Intake Form – Fun Lab Therapy

Welcome

This form will take about 10-15 min to complete. We will endeavour to contact you within 24 hours (or the next working day) to arrange your services.
I am completing this for:*
- My Child (or somebody I care for)
- Myself (I am the client)

Carer Details

This section is about you, the carer. The next page will be about the client you are registering.
Tell us about yourself

This page is for information about yourself.
Carer's First Name*
Carer's Last Name*
Carer's Preferred Name (if different)
Carer's Email*
Carer's Phone*
Carer's Gender*
- Male
- Female
- Intersex
- Transgender
- Prefer not to say
Carer's Date of Birth*
Relationship to client*
Same address as client?*
- Yes
- No
Address*
Suburb*
State*
Postcode*
Languages spoken by carer?
Interpreter required for carer?
- Yes
- No

Services
Services Required (Please describe)*
Current concerns / support required (goals to work on)*
Frequency of service (weekly, fortnightly, etc.)*
Preference for service location*
- Fun Lab Therapy office
- Home
- School
- Kindergarten
- Childcare
- Other
Home based therapy sessions may be beneficial at points during your child’s intervention. Parents and carers are required to remain onsite for home sessions, to maximise the value of home sessions and transference of therapeutic recommendations. Please fill out the following information to prepare our team members appropriately.
Is there adequate on street parking close to the home?*
Are there any restrictions on the parking areas around home?*
Do you have pets? (please ensure all pets are outside of therapy room or restrained)*
Is there adequate mobile reception?*
Is the room clean and free of clutter?*
Is the room adequately heated/cooled?*
Is the room well ventilated?*
Is working area adequately lit?*
Is there adequate seating and desks space available?*
Is there adequate space available for gross motor interventions?*
Are there smokers in the house? Please refrain from smoking during the session*
Has any aggression from the client / other occupants been reported?*
Does the client / other occupants have a psychiatric history?*
Does the client /other occupants have a history of alcohol or drug misuse?*
Is the behaviour of other adult/, family members felt to be appropriate?*
Does the client / other occupants smoke within the home?*
Are there any firearms on the property?*
Any comments?
Fun Lab Therapy reserve the right to deny home treatment sessions should there pose a risk to our staff.

Step 1 of 6

Welcome

Client Details

Carer Details

Tell us about yourself

Funding

Services

Behaviour's of Concern