Wagga OT Intake Form

Intake Form
Wagga Occupational Therapy - ABN 61 684 083 574

Please note: Wagga Occupational Therapy currently only accepts referrals for clients accessing services through the NDIS or Home Care Packages. At this time, we are unable to accept private clients or referrals outside of these. If you have any questions or concerns, please do not hesitate to get in touch.

Participant Information

Participant Full Name *

Participant Preferred Name *

Date of Birth *

Gender

MaleFemaleOther

Participant Address *

Street Address *Street Address line 2

City *

State *

Postcode *

Is the participant living in SIL Housing

YesNo

SIL Housing details

Participant Phone number - if none type NA *

Participant Email Address *

Preferred Method of Contact *

PhoneTextEmail

NDIS Plan Information

NDIS number *

Plan Start Date *

Plan End Date *

Please upload a copy of the NDIS plan

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Does the Plan includes funding periods? *

YesNo

Funding periods and available funds *

Total funding for therapy supports *

Funds confirmed as available and allocated to Wagga OT *

Is the participant Plan Managed or Self-Managed? *

Plan ManagedSelf-Managed

Please Provide Plan Manager Name and Email address if none type NA *

Do you have a Support Coordinator? *

YesNo

Support Coordinator Name and Email address - if none type NA *

Therapy Supports

What type of service are you requiring? *

Primary Reason for referral *

Top 3 Therapy Goals - if none type NA *

Where are sessions to be held *

ClinicHomeSchool/ChildcareOther

If Outside Wagga are you willing to travel to Wagga Wagga *

YesNoOther

Telehealth Acceptable *

YesNo

Diagnosis, Medical and Safety Information

Formal Diagnosis

Diagnosis Details - please provide a copy any reports

Please upload any relevant medical or allied health reports (pediatrician, psychologist, previous occupational therapy assessments, speech pathology)

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Do you have a Current Care Plans - If Yes please provide a copy

YesNo

Please upload any relevant Current Care Plans

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Do you have a Current Behavior Support Plan - If Yes please provide a copy

YesNo

Please upload any relevant Current Behavior Support Plan

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Other Notes or Important Information

Referral Information *

GPSupport CoordinatorSelfOther

Primary Contact:

Name *

Relationship *

Phone number *

Email *

Address *

Primary Decision Maker / Authorised Consent Person:

Name *

Relationship *

Phone number *

Email *

Address *

Name *

Relationship *

Phone number *

Email *

Address *

Next of Kin/Emergency Contact:

Name *

Relationship *

Phone number *

Email

Address *

Who should we send any forms and service agreements to be completed or signed to? *

Will a support worker attend the sessions? *

YesNoOther

Support Worker organisation details *

If this is a self referral, I give permission Aus Disability Support to share relevant reports, information and updates with: *

If self referral, I consent to Aus Disability Support Pty Ltd collecting and storing my personal and medical information for the purpose of providing allied health services. I understand my information will be kept confidential and only shared with relevant professionals involved in my care as required.

Signature of person completing the form *

Draw signature|Type signatureClear

Name of person completing the form *

Relationship to client - if self, type NA *

Date *

Version: 1
Last updated: 07/09/26