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Our Team
Occupational Therapy
Physiotherapy
Speech Pathology
Our Community Partnerships
Join Our Team!
Disability Services
The First Steps
Your Therapy Team
Pricing
FAQS
Helpful Links
Private Services
The First Steps
Rebates
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School Services
School Screenings
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Groups & Workshops
Our School Holiday Group Program
Upcoming Workshops
On-demand Online Workshops
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Our White Zebra Foundation
Support White Zebra Now
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Online Referral Form
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Where We Are
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About Us
Who We Are
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Occupational Therapy
Physiotherapy
Speech Pathology
Our Community Partnerships
Join Our Team
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Disability Services – The First Steps
Your Therapy Team
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FAQS
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Private Services
The First Steps
Rebates
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School Screenings
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Groups & Workshops
Groups & Workshops
Upcoming Workshops
On-demand Online Workshops
White Zebra Foundation
Our White Zebra Foundation
Support White Zebra Now
Contact
Online Referral Form
Contact Us
Who We Are
Send Us Feedback
Home
About Us
Who We Are
Our Values
Our Policies
Our Wize Stars!
Our Blog
Our White Zebra Foundation
Our Team
Our Team
Occupational Therapy
Physiotherapy
Speech Pathology
Our Community Partnerships
Join Our Team
Disability Services
Disability Services – The First Steps
Your Therapy Team
Pricing
FAQS
Helpful Links
Private Services
The First Steps
Rebates
School Services
School Screenings
Staff Training
Groups & Workshops
Groups & Workshops
Upcoming Workshops
On-demand Online Workshops
White Zebra Foundation
Our White Zebra Foundation
Support White Zebra Now
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Online Referral Form
Contact Us
Who We Are
Send Us Feedback
Private Form
Step
1
of
22
- Client Details
0%
Name
*
First
Last
Preferred Name
Date of Birth
*
DD slash MM slash YYYY
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
Unsure
Do you have a Chronic Disease Management Plan (CDMP)?
Yes
No
Please bring a copy to your first appointment. Please be aware this doesn’t cover the full cost of appointments.
Do you have any other funding (e.g. Post Intervention Therapy Services- PITS, Continuity of Support Arrangements - COSA)?
Yes
No
Please provide details...
What is the main reason you are seeking therapy supports for your child?
*
Use the next section to help us understand additional 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)
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 have a preferred clinic location?
*
Southern River
Booragoon
Rockingham
Please provide your available days and times to attend the initial assessment and follow up sessions. We do our best to work with your preferred times however we can’t guarantee we will have these times available.
*
When our therapists have short term availability, we can offer our waitlisted clients a place in our Wize Ignite Program. This consists of a comprehensive discipline-specific assessment and practical recommendations for your child. Please indicate if you would like to be contacted for our Wize Ignite Program?
Yes
No
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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