Start Intake – Develop With Me OT

Develop With Me OT – Start Intake

Intake Form

Thank you for taking the time to complete this form.
The information you share helps me to understand your child’s strengths, routines and challenges so I can best support their growth and participation in everyday life.

This secure form goes straight to Belle. Your information is confidential and stored safely.

Child’s Information

Full name

Date of birth (DD/MM/YYYY)

Gender

Address

School/Daycare

Year Level / Class / Teacher

Parent/Carer

Full name(s)

Relationship to child

Phone number

Email address

Preferred contact method

Reason for Referral & Goals What led you to seek OT support?

What are your goals or hopes for therapy?

Areas of Concern

Play skills Fine motor & hand skills Gross motor & body awareness Self-care Sensory processing Attention & executive functioning Social skills Emotional understanding & confidence Behaviour & participation

Other

Developmental & Medical History Previous assessments/therapy

Paediatrician/other specialists

Ear, nose, mouth concerns

Born full term?

If not full term, weeks’ gestation

Diagnosed medical conditions/disabilities

Medications

Allergies

Daily Life & Routines Describe a typical day

What helps your child feel calm or successful?

What areas of daily life are most challenging?

Practical & Administrative NDIS supports (number, plan dates, plan/self/agency-managed)

Medicare care plan?

Paying privately? (email for invoices)

Best days/times for appointments

Preferred session location

Consent

I give consent for my child to participate in Occupational Therapy assessment and intervention with Develop With Me OT. Information is confidential and stored securely. Information may be shared with relevant professionals only with my consent, except where required by law.

I have read and agree to the consent statement.

Parent/Carer Name

Date

Questions? Email developwithmeOT.belle@gmail.com