Initial Enquiry Form

General Details

Child's First Name *

Child's Surname *

Child's Date of Birth: *

Date of Enquiry *

Parents /Carer's Name *

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?

If Yes - 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.

If Yes please provide a brief description of concern.

EATING *

YesNo

What is your main concern regarding your child's eating? *

SLEEPING *

YesNo

What is your main concern regarding your child's sleeping? (eg. going to sleep / staying asleep/ waking) *

TOILETING

YesNo

What is your main concern regarding your child's toileting? - Day / Night -Dryness/independence *

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

Yes No

What is your main concern regarding your child's gross motor skills ( eg. reduced strength, balance and coordination) *

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

YesNo

What is your main concern regarding your child's fine motor skills? eg. messy handwriting/reduced strength/ fatigue/ reduced coordination and control *

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

Yes No

What is your main concern regarding your child's learning? (learning new information/ restricted interests/frustration) *

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

What are you main concerns regarding your child's Social /Play / Relationship Skills?

WHAT ARE YOUR MAIN CONCERNS REGARDING YOUR CHILD IN THE ABOVE AREAS?

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 which Occupational Therapy services your are looking for? *

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.
• Waiting times may apply for some of our services.
• If you are flexible with your times available - there may be a greater opportunity to provide services sooner.
We look forward to working with you and supporting your child.
Warmest regards

The Viva Kids OT Team.