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- The First Steps
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Contact

Menu

Home
About Us
Our Team
Disability Services
Private Services
- The First Steps
- Rebates
School Services
- School Screenings
- Staff Training
Groups & Workshops
White Zebra Foundation
- Our White Zebra Foundation
- Support White Zebra Now
Contact

NDIS Form

Step 1 of 18 - Client Details

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Name*
First Last
Preferred Name
Date of Birth*
Gender
School/ Day Care (If applicable)
Diagnosis (If applicable)

Name*
First Last
Relationship to client*
Residential Address*
Is this address the same as the client?*
- Yes
- No
Client Address*
Best contact number*
Email*
Would you like to add an additional contact?
- Yes
- No
Name
First Last
Relationship to client
Residential Address
Best contact number
Email

Do you speak a language other than English at home?
- Yes
- No
Which language/s do you speak at home?
Do you require an interpreter?
- Yes
- No
Is there anything else we need to know?

What therapy supports are you looking for?
- Speech Pathology
- Occupational Therapy
- Physiotherapy
- Therapy Support
- Unsure

Use the next section to help us understand the areas you’d like support with. Any information you can provide helps us to match a suitable therapist to your needs.

Do you have any self-care goals?
- Eating and drinking (e.g. swallowing, chewing, eating a variety of foods, using utensils)
- Bathing and grooming (e.g. brushing teeth, washing / brushing hair)
- Toileting
- Dressing
- Sleeping
- Period Management
- Other
- No self-care goals
Additional information

Do you have any communication goals?
- Having a way to communicate
- Understanding what is being said (e.g. answering questions, following instructions)
- Greeting / initiating communication
- Increasing complexity of communication (e.g. more words, longer sentences, conversation skills, correct grammar, etc)
- Speaking clearly
- Literacy skills (e.g. reading, spelling, written expression, reading comprehension)
- Other
- No communication goals
Additional information

Do you have any social skill goals?
- Making and keeping friends
- Understanding social rules
- Sharing and turn taking
- Play skills
- Conversation skills
- Other
- No social skill goals
Additional information

Do you have any learning goals?
- Attention / concentration
- Information processing
- Problem solving
- Organisation
- Understanding concepts
- Memory skills
- Other
- No learning goals
Additional information

Do you have any movement / gross motor skill goals?
- Sitting
- Crawling
- Walking / running
- Climbing / jumping
- Ball skills
- Swimming
- Balance and coordination
- Bike riding
- Community sports and recreation
- Post Botox / serial casting
- Other
- No movement goals
Additional information

Do you have any fine motor skills goals?
- Writing
- Typing / computer skills
- Drawing
- Cutting
- Building / construction
- Other
- No fine motor skills goals
Additional information

Do you have any sensory and emotional regulation goals?
- Coping with sensory challenges (taste, smell, touch, sounds, textures, movement, busy environments)
- Coping with transitions and changes
- Difficulties sitting still
- Body awareness
- Understanding and managing emotions
- Other
- No sensory and emotional regulation goals
Additional information

Do you have any community access and participation goals?
- Travelling safely
- Personal safety (road safety, stranger awareness, running off)
- Accessing the community (shopping centres, medical appointments, parks, eating out)
- Understanding and supporting behaviour
- Other
- No community access and participation goals
Additional information

Do you have any other goals?

Do you currently use any equipment or assistive technology? Please list:*

We provide some supports within the clinic setting. Do you have a preferred clinic location?*
- Southern River
- Booragoon
- Rockingham
Please list other environments in which you would like services to occur.*

Is there any other information you would like us to know?

Thank you for you completing our online referral form! Please click 'Submit' and a WizeTherapy team member will be in contact with you as soon as we have a suitable therapist available.
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Contact Us

Booragoon

Lots 4-6, First Floor Booragoon Commercial Centre,
177 – 179 Davy Street, Booragoon WA 6154
Phone: (08) 9317 7932

Southern River

Unit 5b, 714 Ranford Road, Southern River 6110
Phone: (08) 9485 0056

Rockingham

Waikiki Specialist Centre, Suite 7, 217 Willmott Drive, Waikiki
Phone: (08) 9317 7932

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