Intake Form

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Welcome

Ready to book an appointment? Great, we are here to support you! Our new and improved online Intake Form is the easiest way to begin your journey with us.

Our approach focuses on understanding your story, building strong relationships, and recognising what matters most to you and your loved ones. By sharing a few details below, you're helping us take the first step together. We look forward to meeting you and getting to know your family.

If you need any assistance with filling out the form, we are available to help during business hours on 1800 767 489. Once we receive the completed Intake Form, we will endeavour to contact you as soon as possible to arrange your services.

For whom are you submitting this form?(Required)

A Child (0-18yo)

An Adult (Family member or someone I care for)

Myself

A Client (I am a Support Coordinator, GP, Allied Health, etc)

Services required(Required)

Occupational Therapy

Speech Pathology

Play Therapy

Allied Health Assistance (AHA)

Group Programs

Assessments_FCA_SIL_SDA_Home_Mods_AT_etc

How did you hear about us?(Required)

MyCareSpace Referral Reference Number

Support Coordinator Name

Support Coordinator Email

Support Coordinator Company Name

Practitioner Name

Practitioner Company or Clinic

Practitioner Email

Client/Participant Details

This section is for the person who is going to receive the services ("Participant")

Participant Full Name(Required)

First Last

Preferred Name

Pronouns(Required)

Gender Identity(Required)

Woman or Female

Man or Male

Agender

Gender Fluid

Nonbinary

Transgender

Prefer not to say

Other

Date of Birth(Required)

Day

Month

Year

Participant Phone Number(Required)

Participant Email Address(Required)

Participant Residential Address(Required)

Street Address City State Postcode

Does the participant identify as an Aboriginal or Torres Strait Islander?(Required)

Is an interpreter required for appointments?(Required)

Yes, spoken language interpreter

Yes, Auslan

Yes, other sign language

What language for interpreter?(Required)

Current Diagnosis & Relevant Medical History(Required)

Goals - What is desired to be achieved from this referral?(Required)

Service location preference(Required)

Bundoora Clinic (Northern Suburbs of Melbourne)

Blackburn Clinic (Eastern Suburbs of Melbourne)

Home

College, School, Kinder, Childcare, etc

Telehealth (Online Consultation)

Other (Hospital, SIL/SDA House, Group Home, Etc)

Funding Source(Required)

NDIS

Medicare Plan (A Referral from GP)

Private Health Insurance

Privately funded (Paying from your own pocket)

This field is hidden when viewing the form

NDIS Plan Details

Your NDIS Plan Details

As part of the compliance for Registered NDIS Providers, we need either:

- A full copy of the NDIS plan (most convenient)

A screenshot of:

- the NDIS details (Participant name, NDIS number & dates)

- Goals section and

- Funding Periods section for the therapy funding.

Please upload a copy of the NDIS Plan here

This could be the full PDF or photos/screenshots of the plan details such as name, NDIS number, plan dates, Goals and funding periods for therapy.

Drop files here or

Max. file size: 128 MB.

NDIS Number(Required)

NDIS Plan Start Date(Required)

Day

Month

Year

NDIS Plan End Date(Required)

Day

Month

Year

How are the NDIS funds managed?(Required)

Self-Managed (Invoices are sent to the participant to pay)

Plan-Managed (Invoices are sent to the plan manager to process)

Agency-Managed (Invoices are managed by NDIA)

Plan Manager Company Name(Required)

Plan Manager Email Address(Required)

To receive our invoices

This field is hidden when viewing the form

Medicare Plan Details

Your Medicare Plan Details

As part of the compliance for Registered Providers, we need a copy of the Medicare plan prepared by your GP, along with your GP details.

Please upload a copy of the Medicare Plan here

Drop files here or

Max. file size: 128 MB.

Medicare Number(Required)

Medicare Card Reference Number(Required)

Medicare Card Expiry Date(Required)

Month

Day

Year

What Medicare plan do you have?(Required)

Better Access to Mental Health

Chronic Disease Management Plan / EPC

Helping Children with Autism Medicare Plan

Better Start for Children with Disability

Allied Health Services For Indigenous Australians Who Have Had A Health Check

Other

Referral GP's Full Name(Required)

Referral GP's Provider Number(Required)

Medicare Plan Start Date(Required)

Month

Day

Year

Number of sessions allocated in the Medicare Plan(Required)

This field is hidden when viewing the form

Private Health Insurance Provider Details

Private Health Insurance Provider company name(Required)

Parents Details

Family Information

This section is about the parents of the child

Parent #1 Full Name(Required)

First Last

Parent #1 Relationship to child(Required)

Parent #1 Mobile Number(Required)

Parent #1 Email Address(Required)

Parent #2 Full Name

First Last

Parent #2 Relationship to child

Parent #2 Mobile Number

Parent #2 Email Address

Is Parent #2's residential address the same as the child's address?(Required)

Yes

Parent #2 Residential Address

Street Address City State Postcode

Has your child been involved with Child Protective Services (CPS) or family support services (such as Orange Door) now or in the past?(Required)

Yes

Do you have any parent/caregiver custody arrangements in place for your child?(Required)

Yes, settled court order

Yes, undergoing court proceedings

Yes, with no court order

Not applicable

If you respond yes to the above questions, please provide more information here(Required)

Carer's Details

Your Details

This section is about you, the carer.

Carer Full Name(Required)

First Last

Carer Phone Number(Required)

Carer Email Address(Required)

Relationship to person being referred(Required)

Are you an Emergency Contact for the person being referred?(Required)

Yes

Do you have the same residential address as the person being referred?(Required)

Yes

Carer Address (if different from client's residential address)(Required)

Street Address City State Postcode

Referrer Details

Participant Age(Required)

0-18 yo

19-65+ yo

Referrer Full Name(Required)

First Last

Referrer Phone Number(Required)

Referrer Email Address(Required)

Organisation Name(Required)

Relationship to person being referred(Required)

Preferred contact person for this client(Required)

Referrer

Client/Carer

Carer Full Name(Required)

First Last

Risk Assessment / Behaviours of Concern

At times when participants are upset, frustrated or unable to communicate their needs, they can exhibit behaviours of concern. Please be as honest as possible as this helps our therapists to prepare for successful and engaging sessions.

Are there any behaviours of concern?(Required)

Yes

Unsure

Other

Does the participant have a current Behaviour Support Plan or is awaiting a Behaviour Support Plan?(Required)

Yes

Please upload the Behaviour Support Plan(Required)

Drop files here or

Max. file size: 128 MB.

Please specify the behaviours of concern?(Required)

Verbal aggression

Biting (self or others)

Hitting

Smacking

Hair pulling

Kicking (objects or others)

Strangling

Forceful pushing

Head butting

Eye gouging

Spitting

Other behaviours

Other (please elaborate)

Has any aggression from the client / other occupants been reported?(Required)

Does the participant have any mental health diagnoses or history of psychosis?(Required)

Mental illness such as Schizophrenia, Depression, Anxiety, OCD, PTSD, Bipolar Disorder, Dissociative Disorder, Personality Disorder, Eating Disorder, episode of psychosis.

Does the participant use any regular medications? Are they compliant with taking their medication / Do they need assistance with taking their medication? Are there any instances of psychosis?(Required)

Another adult must be present during any clinic appointment or home visits. Please confirm there is a caregiver, relative or support worker who is available to attend should a home visit be required.(Required)

Has there been any history of physical or psychological violence or threats of violence towards others?(Required)

Any trigger(s) for the above behaviours of concern? (If applicable)(Required)

Triggers can include mention of specific words, phrases, a particular toy or action. Please list in as much detail as possible:

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