Initial Enquiry Form

Thank you for being in touch - via our Initial Enquiry Form.

Please note the following:

Our appointments and availabilities can vary depending on the time of year , and the current capacity of the service.

The service operates for 48 weeks a year - closed for 2 weeks at Christmas and 2 weeks mid year.

We make every effort to reply to Initial Enquiries to advise of our current capacity within 7-10 working days.

Thank you for your understanding - Best Regards The Viva Kids OT Team :)

General Details

Date of Enquiry *

Parents /Carer's First Name *

Child's First Name *

Age of Child: *

Email Address *

Phone Number *

Town/Suburb: *

Name of DayCare / Kindy / School Attended:

Does your child have a Diagnosis Yes / No *

If Yes - At what age was your child diagnosed? *

What is your child's Diagnosis? *

Funding for Occupational Therapy Services (please select your funding type) *

Reason for Seeking Occupational Therapy Services

Do you have any concerns in any of the following areas? Please indicate Yes or No.

EATING *

YesNo

SLEEPING *

YesNo

TOILETING *

YesNo

GROSS MOTOR CHALLENGES - (eg. running, jumping, ball skills, sports) *

Yes No

FINE MOTOR CHALLENGES - eg. Writing /Scissors/ Shoe Laces/Buttons *

YesNo

LEARNING CHALLENGES (eg. reading, writing, maths, remembering everyday information) *

Yes No

BEHAVIOUR CHALLENGES *

YESNO

What is your main concern regarding your child's behaviours? (eg. Compliance/Attention/ cooperating with others/ Anger/ Meltdowns) *

EMOTIONAL CHALLENGES *

YesNo

What is your main concern regarding your child's social /emotional responses? (eg. Overly Emotional / Under- Emotional and reactive /Difficulty with change of routine/ transitions)

RELATIONSHIP/ FRIENDSHIP / PLAY *

YesNo

Has your child seen an Occupational Therapist before? *

YesNo

If Yes - which Occupational Therapy Service and for how long? *

Which other Allied Services is your child seeing currently? (please list) *

Were you referred by someone to our service? Yes/ No - If Yes please advise.

How did you hear about Viva Kids OT? (Please Select from the listed options) *

Please indicate what Occupational Therapy Services you are looking for. *

Assessment Only Assessment and Therapy Therapy ( my child has a recent OT assessment within 6 months)

If you are looking for ongoing therapy - please indicate the frequency of appointments you are looking for? *

WeeklyFortnightly Not Sure

What are your preferred appointment days / times? *

Are you flexible with these times. *

Yes No

Additional Comments: Please add any other relevant information

PLEASE NOTE THE FOLLOWING:
• Our after school appointments are the most sought after for school-aged children.
• If you are flexible with your times available - there may be a greater opportunity to provide services sooner.

Warmest regards

The Viva Kids OT Team :)