Occupational Therapy Questionnaire | Forms | Headstart Intervention Services

Client's name (First name & Surname)

Method of payment

NDIS Self-managed or Agency managed

Health Fund

Enhanced Primary Care

Private

Date of birth

Living arrangements (who does the client live with and relation to them)

Client's age (years and months)

Please select any diagnosis the client as officially received

Autism

Learning disability

Speech / language delays

ADHD

Intellectual disability

Who referred you to Occupational Therapy (OT) and why?

Parent's name

Has the client received OT services before? When, where and why?

Parent contact email/s

Does the client have any other medical conditions and/or medications that we need to be aware of?

Parent contact mobile/s

What concerns do you have for the client? Please explain

What techniques or strategies have you tried for these concerns?

What would you like to achieve from Occupational Therapy?

Has the client had any hearing and vision tests? If yes, when and by who?

Other

Please list any supports the client has at school (eg SSO support, tutoring, visual schedules etc)

Please list any other health practitioners the client currently accesses (eg Psychologists, Speech Pathologists etc)

Please provide your Occupational Therapist with a copy of your NDIS plan (if applicable) on, or prior to, the first session.

What School does the client attend?

How often do they attend?

What year are they in?

What is their teacher's name?