NEW PATIENT INTAKE FORM

We absolutely love working with families and supporting children to achieve their goals.

Please complete the form with as much detail as you can. It will help us to better understand your child and how we can best support them.

If you do have any questions, please give us a call on 02 6189 8986.

General Information - Child

Child's first name *

Child's surname *

Child's Preferred Name/Nickname

Date of birth *

Gender: *

Child's General Practitioner *Please list the GP name and practice

Child's Paediatrician:If currently seeing a Paediatrician

I consent to Canberra Children's Physiotherapy corresponding with my child's Medical Team (GP and/or Paediatrician) in regards to their assessment and treatment plan. *

Does your child have any formal diagnoses? *

Is your child currently taking any medications?Please list any medications that your child is currently taking

What is your home address? *

Street address *

City *

State *

Postcode *

School/Daycare

How did you hear about Canberra Children's Physiotherapy? *

Parent/Guardian 1 Contact Information

Parent/Guardian 1 Full Name *

Email Address (1) *

Mobile Number (1) *

Parent/Guardian 2 Contact Information

Parent/Guardian 2 Full Name:

Email Address (2):

Mobile number (2)

Main Concern

I would like to see *

PhysiotherapyOccupational TherapyToe Walking Clinic/Combined Physio and Podiatrist Clinic

Physiotherapy Information

What is the reason for booking with us? *

Torticollis/Neck tightnessHead strength concernPlagiocephaly/Brachycephaly/Flat spotGeneral discomfort/tightness/weaknessFoot concern (positional talipes, Metatarsus Adductus)Hip concern (clicking hip/hip dysplasia/uneven creases)Delayed Gross Motor Milestones Other

Other *

Have you previously trialed any treatment for this concern or are currently seeing another health provider for co-treatment of this concern? If yes, please provide any details you feel are relevant

Please provide any relevant details around your child's birth history *For example, vaginal vrs scheduled caesarean birth vrs emergency caesarean birth, any equipment (e.g. forceps/vacuum), gestational age of baby at birth, any NICU/SCN, any medical concerns (e.g. jaundice).

Have you seen any other health professionals since your child's birth?For example, Lactation Consultant, Paediatrician, Tongue Tie Release, Osteopath, Chiropractor, Other

What are your main goals of physiotherapy? *

Is there any other information you think we should know to better support your child?

What is the main concern that has prompted you to book an appointment? *

What are your current goals of physiotherapy? *

Does your child have any significant medical or birth history?For example, premature birth, any NICU/SCN, any medical concerns (e.g. jaundice/significant reflux/allergies requiring medical input), any relevant diagnoses, any previous medical treatment

Is there anything else you think we should know to best support your child?

Does your child have any diagnoses? *

Please provide more detail:

What outcome/s are you hoping to achieve by working with us? *

How will you know when you have achieved this goal? *

How much time (outside therapy appointments) do you have each day/week to implement the strategies that we recommend to help you achieve your goal? *We know things come up and some days have more time than others - we're keen to get an approximate

Is your child currently working with any other allied health therapy providers? *

Yes No

Does your child have: *

Daytime Urinary IncontinenceDaytime Fecal Incontinence ConstipationNight time wetting

How long has this been a concern for? *

Has your child previously achieved continence? *

Have you trialed any interventions in the past? *If yes, please provide details

Are you currently working with any other health professionals? *

YesNo

Is there any other information that you feel is relevant for us to know to best support your child?

What are your child's symptoms/injury? *

How long has this been an issue? *

Is this a new issue or recurring issue? *

What are your treatment goals? *

Does your child play any sport or participate in physical based extra-curricular activities? Please list these below.Please also indicate the frequency of training/games

OT Goals

What are your OT goals that you are hoping to achieve by working with us? *

What impact will achieving these goals have on your child and family life? *

Are your goals home or school based (or both)? *

If school based, do you think your child's school/teacher will be receptive to input from an external therapist?

How will you know when you have achieved these goals? What will this look like for your child? *

How much time outside of therapy appointments do you have each day to implement the strategies that we recommend to help you achieve your goal? *

Developmental Domains

Self-Care Skills *Refers to following routines, feeding, brushing teeth, dressing, packing lunch, getting ready for school

Sensory Processing SkillsRefers to child's ability to process sensory information within their environment - e.g. auditory input, visual input, movement

Emotional RegulationRefers to child's ability to self-identify emotions and have strategies to support regulation

Play and Social SkillsRefers to a child's ability to engage with peers, initiate play and interact socially in small or big groups

Fine Motor SkillsRefers to a hand movements/tasks such as handwriting, doing up buttons or zippers, using cutlery

Gross Motor SkillsRefers to big movements such as running, jumping, hopping, throwing and catching. These skills more fall under the scope of a physiotherapist, however an OT sometimes will incorporate these into sessions

Other (anything else):

How can we best support you

What are the 3 most important characteristics that you are hoping to find in your Occupational Therapist? *

Is there a specific OT treatment intervention that you have trialed in the past that did or did not work? *

What is your understanding of Occupational Therapy and what OT's work on? *

What does the 'Neuroaffirming' mean to you? *

When are you hoping to start OT with us? *

As soon as possibleWe're waiting on NDIS funding to be approved

Does your child have a multi-disciplinary team already involved in therapy? *

YesNo

Is there any other information that you feel is relevant that we should know?

We are seeking an appointment for: *

Toe Walking Complex Foot Assessment

How long has your child been Toe-Walking for? *

How often does your child toe-walk? *Is it always/sometimes/rarely? Does it occur in shoes or out of shoes? Does it happen more at home or when out?

What is your child's foot concern? *

How long has it been a concern? When did it start? Was it caused by an injury/incident?

Have you trialed any other treatment in the past for this concern? *Please provide details of past intervention that has been suggested or trialed

Allied Health and Medical Team

Please include the name of the therapist and practice name. If you have their contact email, please add it in also.

Speech Therapist

Occupational Therapist

Psychologist

Other Allied Health Practitioner

Other Medical Specialist

I consent to Canberra Children's Physiotherapy contacting the listed medical and allied health providers to discuss my child's therapy plan or to obtain additional information (noting Canberra Children's Physiotherapy will only contact other providers after the initial appointment)

Supporting Documentation

Whilst not compulsary, some of our clients have lots many reports/documents that they would like attached to their child's file. If you have any documents that you wish to submit with your intake form, please use this section to do so.

Do you have any documents you wish to upload?

Browse

Please convert any documents you wish to upload to a pdf

Contact

I consent to SMS reminders *

I consent to email reminders/messages *

Funding

We ask about NDIS funding as often children who are accessing the NDIS may be plan-managed which means that we may need to send invoices to a 3rd party or they may require specific reports to justify further funding a the end of a plan period.

Our fees are consistent across all our clients and aren't impacted by NDIS funding

Does your child have NDIS funding? *

Who is your child's plan manager?

What is your plan managers email address for invoices?

What is your child's NDIS number? *

When does your child's NDIS plan expire? *This will help us plan when we may need to write an NDIS report

Consent

I consent to the provided information being stored securely on Canberra Children's Physiotherapy's clinical system *

I confirm that above information I have provided is true, complete and accurate. *

I understand there is a cancellation timeframe of 2 business days (noting Canberra Children's Physiotherapy is open Monday-Friday), and that failure to cancel within that time will result in the full appointment cost to be invoiced. *

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