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East Kimberley Clinic
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For Therapists and Students
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NDIS Funding
Home
Services
Therapy
Occupational Therapy
Clinical Psychology
Behaviour Support Services
Somatic Movement Therapy
Group Therapy Programs
Creative Minds
Sense Rugby
Move and Mingle
Pre Kindy Group
Parent Workshops and Groups
Therapy Camps
Adventure Camps
Boys Camps
Camp Confidence
Girls Camps
East Kimberley Clinic
Functional Assessments
Therapy Intensive Session Blocks
Events
Resources
For Teachers and Parents
For Therapists and Students
Therapy Camp Supports
For Police and First Responders
Fees and Rebates
NDIS Funding
Home
Services
Therapy
Occupational Therapy
Clinical Psychology
Behaviour Support Services
Somatic Movement Therapy
Group Therapy Programs
Creative Minds
Sense Rugby
Move and Mingle
Pre Kindy Group
Parent Workshops and Groups
Therapy Camps
Adventure Camps
Boys Camps
Camp Confidence
Girls Camps
East Kimberley Clinic
Functional Assessments
Therapy Intensive Session Blocks
Events
Resources
For Teachers and Parents
For Therapists and Students
Therapy Camp Supports
For Police and First Responders
Fees and Rebates
NDIS Funding
Home
Services
Therapy
Occupational Therapy
Clinical Psychology
Behaviour Support Services
Somatic Movement Therapy
Group Therapy Programs
Creative Minds
Sense Rugby
Move and Mingle
Pre Kindy Group
Parent Workshops and Groups
Therapy Camps
Adventure Camps
Boys Camps
Camp Confidence
Girls Camps
East Kimberley Clinic
Functional Assessments
Therapy Intensive Session Blocks
Events
Resources
For Teachers and Parents
For Therapists and Students
Therapy Camp Supports
For Police and First Responders
Fees and Rebates
NDIS Funding
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Caregiver Pre Therapy Questionnaire and Consent
Caregiver Pre Therapy Questionnaire and Consent
Step
1
of
2
50%
Date form Completed:
*
DD slash MM slash YYYY
Child’s Full Name:
*
Date of Birth:
*
DD slash MM slash YYYY
School Or Daycare Attending:
Gender alignment:
*
Female
Male
Non-binary
Prefer not to say
Other
Primary Contact Details
Name:
*
Relationship To Child:
*
Address:
*
Primary Phone Number:
*
Secondary Phone Number:
Email:
*
Preferred Method of Contact:
Email
Phone Call
Text
Secondary Contact Details
Name
*
Relationship To Child:
*
Phone Number
*
Secondary Contact Email
Secondary Contact Email
Services you are seeking to receive from Calm and Connected:
*
Occupational Therapy - Perth
Occupational Therapy - Kununurra
Psychology
Speech Pathology
Social Work
Please note; children are not able to access Calm and Connected's Psychology services if they are receiving Psychology support else where.
Does your child have a current behaviour support plan?
Yes
No
Who should be provided with any updates to therapy services?
Who will be involved in therapy?
Are there any other people (support workers/ teachers/ family members) that will be involved in learning how to support the client?
Health Information
For the below questions, please answer yes or no, and if yes, please include relevant details.
If your child takes any medications, please list them below:
If your child has any allergies, please describe them below:
Does your child have any medical conditions or diagnosis?
Does your child have asthma?
*
Yes
No
Does your child have a history of seizures?
*
Yes
No
Does your child wear glasses?
*
Yes
No
Does/has your child experienced frequent ear infections? Or have grommets?
*
Yes
No
Does your child have ambulance cover?
*
No
Yes
In case of emergency, do you give us permission to phone an ambulance on your child's behalf?
*
Yes
No
Has your child spent long periods in hospital? If yes please describe:
Were there any complications during pregnancy or birth?
Is your child currently or previously received allied or medical health services? Or have received health services in the past?
Speech pathology
Physiotherapy
Psychology
Please note; you are not able to access Calm and Connected's Psychology services if you are receiving Psychology support else where.
Paediatrician
Neurologist
Other:
Is there any other relevant past medical history you would like to share with us?
Self care
For the below questions, please include any relevant information.
Does your child require assistance with any of the following tasks?
Dressing
Sleeping
Eating
Showering
Toileting
None of the above
What is your child’s typical bedtime routine? What happens if this is disrupted?
Does your child wake during the night? If yes, how many times and what strategies do they use to help get back to sleep?
Do they have any difficulties at meal times? Is your child a fussy or resistant eater?
Social and Emotional Information
For the below questions, please include any relevant information.
Who lives at home with your child?
*
Please describe any cultural considerations, cultural background and/or any supports required:
Are there any of the following in place:
*
Violence and restraining orders
Department of Child Protection
Restrictions on who can receive information
Custody arrangements
None of the above
Please describe any difficulties occurring at home:
Please describe any difficulties occurring at school/daycare:
Is your child able to form and maintain relationships/friendships with others?
How does your child tell you how they are feeling or what has happened to them? Can they talk about their emotions and express their feelings in words?
What are your child’s interests? What activities do they like to do?
Your child and their environment
For the below questions, please include any relevant information.
Do loud noises bother your child?
Yes
No
Is your child bothered by the feel of certain fabrics?
Yes
No
Is your child sensitive to certain smells?
Yes
No
Does your child like to run, jump and move around lots during the day?
Yes
No
Sometimes
Strengths
What are your child's strengths?
Areas to develop
What are your child’s needs and areas for development?
Do you have any concerns about your child's learning skills? Do they have difficulties with literacy and language?
Why have you decided to speak to an Occupational Therapist, Speech Pathologist and/or Psychologist?
Is there anything else you would like to tell us?
Therapy Assistant Dogs
Our therapy assistant dog teams work from our HQ or may meet for appointments at local parks. They cannot come into others homes. Even if you are not working with one of our teams who are in training, please complete this section so we know if you are coming to appointments at our HQ.
Please select the option or options that apply for your child:
*
My child has an allergy relating to dogs
My child has a fear of dogs
My child enjoys being around dogs and we are interested in working with therapy assistant dog teams
A family member or support person attending appointments has a fear of dogs
A family member or support person attending appointments has allergies relating to dogs
We are not interested in animal assisted therapy
Payment Details
Payment Type
*
NDIS Plan Managed
NDIS Agency Managed
Self managed NDIS
Privately Paid
Medicare Referral
Fahcsia funding; Better start/Helping Children with Autism Funding
NDIS number:
*
Planners name and contact details:
*
Planners name and contact details:
*
Copy of NDIS Plan
*
Max. file size: 128 MB.
Please note; we need to have on file a plan that shows persons name, NDIS number, plan dates and funding type
Copy of Medicare Referral from GP
*
Max. file size: 128 MB.
Please note; sessions are to be paid in full and receipts taken to medicare to claim rebate.
How many Medicare sessions will be allocated to Calm and Connected (maximum 5 per calendar year)?
*
Consent to Share Information
Please select those who you consent to us sharing information with:
Additional Caregivers
School/Daycare Administration
Teacher/ EA/ Childcare Educators
Other Therapy Providers
GP Administration
GP
Support Coordinator
Plan Manager
Please provide name and contact details of school/daycare
Please provide name and contact details of before/after school care
Please provide name and contact details of Health Professionals
Please provide name and contact details of Support Workers
Please provide name and contact details of Support Coordinator/Plan Manager
Please provide name and contact details of other
Photo/Video Consent
I hereby give my permission to the staff of Calm and Connected to make photographic, audio, or visual recordings of my child while attending Calm and Connected’s Therapy Programs. Photos/Video of my child may be used as indicated below:
To be used for internal supervision, training and education for the staff of Calm and Connected.
*
Yes
No
To be used for external supervision, training and workshops. i.e. at parent and therapist workshops.
*
Yes
No
To be used on our online learning portal for education and training purposes.
*
Yes
No
For photos to be used on Calm and Connected’s website and marketing materials to support the description of their programs – you will be notified
*
Yes
No
Name:
*
Date:
*
DD slash MM slash YYYY
By accepting these Terms of Service, you are entering into a legally binding contract, so please consider carefully whether our services are right for you and contact us before requesting our services if you have any concerns.
*
Please view our Terms of Service found on our website here: https://calmandconnected.com.au/termsofservice/
Yes I consent and agree to Calm and Connected's Terms of Service. I agree to the Cancellation Policy and Billable Terms.
X
X
