Intake Form
Thank you for choosing All Smiles OT! We cannot wait to meet you and help you with your goals - please fill this form out and we will be contact with you in 2 business days.

Please note - we service private, NDIS self-managed and NDIS plan managed clients.
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Email *
Please aim to fill out all the questions so we can best help you
Client full name *
Client DOB *
MM
/
DD
/
YYYY
Address *
Who does client live with? (Names and ages) *
Parent/ carer name (person filling this form out) - N/A if client filling this form out
Mobile/ best contact number *
Describe your child's birthing history (how many weeks) and natural/ Caesarean birth *
Were there any complications during or after the pregnancy? *
Tick all that apply *
Required
Is your child on any prescribed medication (please describe)? *
Does your child have any allergies? *
Which school or early learning centre do you/ does your child attend? How many days a week? *
Client diagnosis (if any) - please write these down or write N/A *
Has your child's vision been tested? *
Has your child's hearing been tested?
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Funding *
I/ My child needs support with (please check all that apply) *
Required
My child/ I communicate in this way: *
Availabilities (please check all that apply) (We are open Monday - Thursdays for client consultations). *
Required
I am looking for *
Required
The MAIN goal I would like to work on is.... *
Which extra curricular activities does your child/ do you engage in? *
Write down any other information you feel would be helpful for the therapist to help you/ your child respond well to therapy
How did you find out about All Smiles?
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