Lil Peeps OT For Kids Referral Form

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The information you provide in this form is confidential, and it provides Lil Peeps with essential information about your child that can assist in providing an Occupational Therapy Service. We are currently taking referrals for our waitlist for children 3 -12 years. and once your referral is received our administration team will be in contact with you, within 5 business days.

## Please note we are not accepting referrals for children entering high school, or current high school students.

Email *

Child's Name *

Date of Birth *

YYYY

Address

Gender

Male

Female

Prefer not to say

Other:

Clear selection

Does your child have a diagnosis from a paediatrician, or in the process of receiving a diagnosis? If so please detail:

Are you accessing funding from NDIS? (please note we only provide support to families who self manage or plan manage their funding. Lil Peeps OT is not a registered NDIS provider.)

Yes

Clear selection

Are you currently applying for funding from NDIS? (please note we only provide support to families who self manage or plan manage their funding. Lil Peeps OT is not a registered NDIS provider.)

Yes

Clear selection

School Attending *

Parent / Guardian Name *

Parent / Guardian Phone Number *

Year Level at School *

Teacher's Name

Teacher's Email Address

Developmental History - please detail any history relating to the development of your child you think may be relevant to the assessment or therapy process.

Have you accessed OT support previously?

Yes

Clear selection

What are the main areas you are currently seeking support for?

Self Regulation;

Handwriting and fine motor skills

Gross motor coordination

Self care skills

Technology skills

Unsure

Do you know which assessment option you would like to commence with? *

Initial Occupational Therapy Assessment kindy / pre primary $350 (please note, this addresses physical skills and prewriting only, it does not address self regulation)

Initial Occupational Therapy Assessment year one and up $500 (please note, this addresses physical skills and handwriting only, it does not address self regulation)

Sensory profile assessment to support self regulation $450

NDIS client - customised assessment ($180 / hr)

No assessment required as recent OT assessment data available to share

Other:

Required

Please indicate which agencies you give authority for information to be shared with *

Teacher and School

Other agencies and therapists

I do not consent to share information (this may impact on our ability to provide a school based service)

Required

Are there any family court orders in place that Lil' Peeps needs to be aware of? *

Yes

Do you consent to photos being taken of your child for marketing purposes?

Yes

Clear selection

I consent to my child having an Occupational Therapy assessment and therapy (if recommended) by a therapist of Lil' Peeps OT for Kids. A travel fee may also apply for the service.

I understand that this is a private billing practice and I will be required to pay within seven days of receiving an invoice. (Administration fees are charged for late payment and debt collection services may also be utilised)

Yes I provide consent and understand billing requirements

Required

A copy of your responses will be emailed to the address you provided.

Submit

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