Client Intake Form

Thank you for your interest in Nepean Speech and Occupational Therapy (NSPOT).

Please complete the below intake form to help us learn more about you and the support you are seeking. The information provided assists our team in determining the most appropriate service, clinician, and appointment options for you.

Once submitted, our administration team will review your enquiry and contact you regarding availability, waitlist timeframes, and next steps.

If you have any relevant reports or documentation, you are welcome to upload these as part of the form.

Service Type

What support are you seeking? *

Exercise Physiology

Personal Information

First Name *

Last Name *

Date Of Birth *

Sex

Contact Number *

Email Address *

Funding

If yes, how is it managed? *

Self-ManagedPlan-Managed

Medical History/Health Conditions

Do you have a formal medical diagnosis/health conditions? *

Exercise Physiology Information

What would you like help with? (please tick all that are applicable)

What would you like help with? *

Appointment Preferences and Service Options

What time windows generally suit you? (select all that apply)

Early Morning (8am)During School hours (9am–3pm)Afternoon (3pm–5pm)Flexible

Any specific availability notes? (optional)

Referral Information

How did you hear about us? *

If other, please specify *

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