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 your child and the support you are seeking. The information provided assists our team in determining the most appropriate service, clinician, and appointment options for your family.

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? *

Speech Therapy Occupational Therapy Both Speech and Occupational TherapyExercise Physiology

Personal Information

First Name *

Last Name *

Date Of Birth *

Sex

Parent's Name *

Contact Number *

Email Address *

School/Preschool

Funding

Does your child have an NDIS Plan? *

Yes No

If yes, how is it managed? *

Self-ManagedPlan-Managed

Medical History

Does your child have a formal medical diagnosis or disability? *

Speech, Language and Literacy Information

Please outline your main concerns for your child and who first observed them? *

Occupational Therapy Information

Please outline your main concerns for your child and who first observed them? *

Sensory Processing Continued (please tick all that are applicable)

Is your child more active than other their age? Does your child become upset, overwhelmed or avoid busy places?Does your child have difficulty completing quiet activities? Does your child avoid contact with others, such as being touched by others?Does your child have difficulty tolerating grooming activities such as brushing teeth or hair? Does your child avoid or dislike particular fabrics/ avoid certain clothing? Is your child easily distracted?Does your child become upset or fearful of loud noises?Is your child a fussy eater and avoids certain food textures, tastes, smells or colours?

Exercise Physiology Information

Please outline your main concerns for your child and who first observed them? *

Does your child have difficulty with the following (please tick all that are applicable)

What would you most like your child to improve or be able to do? *

Appointment Preferences and Service Options

Are you open to seeing a Therapy Assistant? *

YesNo

A therapy assistant is a team member who supports therapy sessions under the guidance of a qualified therapist. They are supervised by an experienced clinician while assisting with your child’s therapy program.

Are you open to participating in groups? *

YesNo

You can participate in groups while your child is still waiting for services

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

Before School (8am)During School hours (9am–3pm)After school (3pm–5pm)Flexible

Any specific availability notes? (optional)

Referral Information

How did you hear about us? *

If other, please specify *

Attach any reports or relevant documents (e.g., previous Speech/Occupational Therapy reports, paediatrician reports, school reports etc.)

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