Skip to content

0449 612 283
Subscribe

Home
About
- Meet The Team
- Join The Team
Services
- Operating Hours
Fees and Funding
Therapy Ideas
Resources
Contact

Intake Form

Step 1 of 6

16%

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.
Carers First Name*
Carers Last Name*
Carers Preferred Name (if different)
Carers Email*
Carers Phone*
Carers Gender*
- Male
- Female
- Intersex
- Transgender
- Prefer not to say
Carers 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

Client Details

This page is for information about the client you are registering.
Client First Name*
Client Last Name*
Client Preferred Name (if different)
Client Phone Number (if applicable)
Client Email (If applicable)
Client Address*
Client Suburb*
Client Postcode*
Client Date of Birth*
Client Gender*
- Male
- Female
- Intersex
- Transgender
- Prefer not to say
Does the client identify as an Aboriginal or Torres Strait Islander?*
- Yes
- No
- Unknown
Does the client have a diagnosis?*
- Yes
- No
Primary Diagnosis*
Client School Name (If applicable)

Funding
Funding Source*
- NDIS
- Medicare
- Private Health
- Self Funded
Do you have a copy of your NDIS plan to upload?*
- Yes
- No
Upload a copy of your NDIS plan*
Plan Start Date*
Plan End Date*
NDIS Number*
How are the funds manage*
- Agency Managed
- Self Managed
- Plan Managed
Funding amount available
Plan Manager Company*
Plan Manager Contact Person*
Plan Manager Phone*
Plan Manager Email*
Do you have a copy of your Medicare plan to upload?*
- Yes
- No
Upload a copy of your Medicare plan*
Medicare Number*
What Medicare plan do you have?*
- Better Access to Mental Health
- Chronic Disease Management Plan / EPC
- Helping Children with Autism Medicare Plan
- Better Start for Children with Disability
- Allied Health Services For Indigenous Australians Who Have Had A Health Check
Referral Name*
Referral Provider Number*
Plan Start Date*
Number of Sessions
Please type your insurance provider*

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
- Kindy
- Childcare
- Other
Environmental Assessment
Parking*
- Is there adequate parking close to the home?
- Are there any restrictions on the parking areas around home?
- Is the therapist able to park facing away from the property?
Parking Comments/Actions
Are floors in good condition and not slippery?*
Are floors in good condition and not slippery? Comments/Actions
Are stairs well-lit with handrails?*
Are stairs well-lit with handrails? Comments/Actions
Are any pets adequately restrained?*
Are any pets adequately restrained? Comments/Actions
Is there adequate mobile reception?*
Is there adequate mobile reception? Comments/Actions
Is there adequate mobile reception? Comments/Actions
Are there any immediate neighbourhood risks?*
Are there any immediate neighbourhood risks? Comments/Actions
Work Environment
Is the room clean and free of clutter?*
Is the room clean and free of clutter? Comments/Actions
Is the room adequately heated/cooled?*
Is the room adequately heated/cooled? Comments/Actions
Is the room well ventilated?*
Is the room well ventilated? Comments/Actions
Is working area adequately lighted?*
Is working area adequately lighted? Comments/Actions
Do doors have locks? If so, where?*
Do doors have locks? If so, where? Comments/Actions
Is there adequate seating and desks space available?*
Is there adequate seating and desks space available? Comments/Actions
Is there adequate space available for gross motor interventions?*
Is there adequate space available for gross motor interventions? Comments/Actions
Is the noise level manageable?*
Is the noise level manageable? Comments/Actions
People
Has any aggression from the client / other occupants been reported?*
Has any aggression from the client / other occupants been reported? Comments/Actions
Does the client / other occupants have a psychiatric history?*
Does the client / other occupants have a psychiatric history? Comments/Actions
Does the client /other occupants have a history of alcohol or drug misuse?*
Does the client /other occupants have a history of alcohol or drug misuse? Comments/Actions
Is the behaviour of other adult/, family members felt to be appropriate?*
Is the behaviour of other adult/, family members felt to be appropriate? Comments/Actions
Does the client / other occupants smoke within the home?*
Does the client / other occupants smoke within the home? Comments/Actions
Are there any firearms on the property?*
Are there any firearms on the property? Comments/Actions
Additional Relevant Information
Other Possible Risks*

Behaviours of Convern
On occasions for a variety of reasons, children can exhibit behaviours of concern. Having our therapists aware of these behaviours will help to prepare them to work as effectively as possible with your child. Please tick below if you child has shown any of the following behaviours of concern.
- Biting (self or others)
- Hitting
- Smacking
- Hair pulling
- Kicking (objects or others)
- Strangling
- Forceful pushing
- Head butting
- Verbal aggression
- Eye gouging
- Spitting
- Other behaviours
Other behaviours (please list):
Triggers (words, phrases/ topics):

Privacy Policy

Copyright 2013 - 2020 © Fun Lab Therapy. Powered by

Home
About
- Meet The Team
- Join The Team
Services
- Operating Hours
Fees and Funding
Therapy Ideas
Resources
Contact