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Intake Form
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Don’t wait any longer,
discover that you are more than able.
Fill out an intake form below and start your child on a path to being more than able.
Contact Information & Appointment Preferences
Childs Name
*
First
Last
Childs DOB
*
Day
Month
Year
Gender
*
Male
Female
Other
Parent/Guardian Name
*
First
Last
Contact Phone Number
*
Email
*
Address
*
Street Address
City
State
Background Information
Who lives at home?
*
Add
Remove
Please list names, ages, employment and relationships
Does your child attend formal school or daycare?
*
Yes
No
Facility Name?
*
What is the teachers name and contact information?
*
What grade is your child in? (if applicable)
Funding
What funding source are you using?
*
Private
NDIS
If NDIS Funded, How Are You Managed?
*
Plan
Self Managed
NDIS Number
*
NDIS Plan Date
*
Day
Month
Year
What services do you require
*
Occupational Therapy
Physiotherapy
Holistic Autism Assessment
Therapy Assistance
Group Therapy
Select All
Medical History
Please list your child's Paediatrician
First
Please list your child's GP
*
First
Please list all current Allied Health Input (OT, SLT, Psych, Physio, Dietician etc)
Paediatrician
Yes
No
Details
Speech Pathologist
Yes
No
Details
Occupational Therapist
Yes
No
Details
Physiotherapist
Yes
No
Details
Psychologist
Yes
No
Details
Dietician
Yes
No
Details
Medical Specialist
Yes
No
Details
Concerns and Goals
What are your main concerns for your child?
*
What is your primary goal for therapy?
*
Does your child have any medical conditions, adaptive equipment use or other concerns we need to be aware of?
(seizures, behaviours of concern, allergies, wheelchair user, AAC user, non-speaking, very high anxiety etc)
Is there any further information you would like to share with your therapist/s?
Appointment Preferences
What are your preferred days?
*
Monday
Tuesday
Wednesday
Thursday
Friday
Please select up to 3
What is your preferred time of day for appointments?
*
Morning
Afternoon
Around midday
Any specific time constraints or preferences?
(e.g., after school, specific times to avoid)
How did you hear about us?
Cancellation Policy
More Than Able requires notice of 48 business hours prior to the appointment for cancellation, unless a medical certificate is provided, otherwise, 90% of the invoiceable cost will be charged. For our outreach services, the notice required for cancellation of appointments is 5 business days. Do you understand and accept the cancellation policy?
I agree to the terms and conditions above
*
Yes
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About
About Us
Occupational Therapy
Physiotherapy
Holistic Autism Assessment
Hydrotherapy
Group Therapy
Outreach Service
Funding
Contact
Intake Form
