Submit a Referral to Allied Kids Therapy

Step 1 of 6

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Client information

Name(Required)

Gender

Date of Birth(Required)

MM slash DD slash YYYY

Preferred Pronoun

Diagnosis(Required)

Do you identify as Aboriginal or Torres Strait Islander?

Yes

Contact information

Phone number(Required)

Email address(Required)

Address(Required)

Other contacts

Contact list

Please name all relevant persons who may be present with client during therapy:

Name

Relationship

Name

Relationship

Name

Relationship

Name

Relationship

Care team list

Please name all relevant persons support your child:

Name

Relationship

Name

Relationship

Name

Relationship

Name

Relationship

What service are you looking for?(Required)

NDIS

Private

Reason for referral

Please outline your reason for referral and what you hope to achieve with therapy:

reason for referral – private

Other (please describe):

Contact information

NDIS Number

NDIS Plan Start/End Dates

Plan Management Style

Plan Manager Details

Reason for referral

Please outline your reason for referral and what you hope to achieve with therapy

Rason for referral – NDIS

Services Requested

Please mark the services that apply:

Speech Pathology

AAC

Aphasia

Minimally or Non speaking

Stuttering

Dyslexia

Understanding language

Social Skills

Speech Sounds

Understanding language

Literacy

Language Assessment

Using language/talking

Voice

Fussy Eating

Late talking

School Readiness Assessment

Other (please describe)

Occupational Therapy

Sensory needs

Fine Motor Skills

Activities of Daily Living (ADLS), such as bathing, toileting, dressing, sleeping

Social skills and participation

Motor planning/Development Coordination disorder

Gross Motor skills

Behavioral challenges

Play/DIR Floor time

Parent support/Parent sensory profile

Visual Motor Integration

Emotional regulation

Classroom adaptations

School and education participation

Executive function

Assessments

Functional Capacity Assessment

Growth and development assessment

School readiness assessment

Handwriting assessment

VCE Assessment (text and exam accommodations)

Visual Perceptual Assessment

Other (please describe)

Physiotherapy

Please outline the needs

Information Privacy

Are there any current Family Court Matters in relation to the client?(Required)

Yes

If yes, please attach a copy of the order

Attach file

Max. file size: 500 MB.

Please note that by completing and returning this form you consent to allied Kids Therapy using 5 hours of NDIS funding for initial case history and assessment.

Please note that Allied Kids Therapy clinicians generally complete your initial case history and assessment within the first 5 hours of therapy. Your clinician will provide you with a service agreement and therapy support plan outlining the estimated therapy hours after the initial 5 hours.

Referral

Client information

Contact information

Contact list

Care team list

Reason for referral

Contact information

Reason for referral

Services Requested

Information Privacy

Access qualified clinicians, where it suits you

Access qualified clinicians, where it suits you