Thank you for requesting an appointment with Next Challenge

Please complete the following questions so that we can provide you with the best possible service.

Today's Date *

Child's Name *

 

Child's Sex *

Male Female Other

Please advise how the child identifies *

Child's Date of Birth *

Your Name *

 

Your Relationship to Child *

Best Phone Contact *

Best Email Contact *

Street Address *

Suburb *

Postcode *

How did you hear about Next Challenge? *

Medical referral Google / internet searchFamily / friend recommendation Teacher / school recommendation Autism Association National Disability Insurance Agency (NDIA) Wanslea Sibling attended Next Challenge Social MediaOther

Would you like an interpreter for appointments? *

YesNo

If yes, which language / dialect? *

Are you seeking services at one of our established school-based clinics? *

YesNo

School-Based Clinics

Child's School *

St Helena'sRegent College (Please note, there is currently a waitlist for services until Term 2 2022)St Paul'sPeter Carnley - Wellard CampusPeter Carnley - Calista Campus

Teacher's Name *

School Year *

Are you available to attend sessions at school? *

YesNo

Emergency Contact Details

In case of emergency, we require details for an alternate contact person for your child.

Emergency Contact Name *

Emergency Contact Number *

Relationship to Child *

Custody & Court Orders

Is the child identified in this booking form currently in the care or being supported by the Child Protection & Family Support (CPFS) team? *

YesNo

Case Manager Name

Case Manager Email Address

Case Manager Contact Number

Please continue filling out this current form, and open this link in another tab to complete after 

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Is a current family or parenting court order in place *

YesNo

Please describe the nature of the court order and any other relevant information pertaining to this order *

Please upload any relevant court order documentation

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How can we help?

What type of service are you looking for? *

Speech PathologyLiteracy Check Assessment (Speech Pathology)Feeding and/or mealtime concerns (Speech Pathology and/or OT)Occupational TherapyPhysiotherapyDietetics / NutritionWe are not sure at this stage and would like your help with this

How will you be accessing our Services? *

Self funded - we will pay in full and/or arrange private health insurance reimbursementWe have a Medicare care plan in place with our GP - Please email us a copy of the planWe have an NDIS Plan (self managed) - Please email us a copy of your planWe have an NDIS Plan (plan managed) - Please email us a copy of your planWe are not sure as yet and would like to talk to someone more about our options

Please note, Next Challenge is not an NDIS agency registered provider. Unfortunately, this means we cannot provide services to NDIS agency-managed participants.

Please confirm the name of your plan manager (i.e. company that pays NDIS invoices)

Does your child have a diagnosed developmental delay or disability?

YesNo Not yet - we are working with a medical team

If yes, what diagnosis/diagnoses does your child have?

Please provide a brief outline of your current concerns for your child *

When are you available for appointments?

Morning only Afternoon only After-school onlySchool hours only We are flexible

Monday

Morning only Afternoon only After-school onlySchool hours only We are flexible

Tuesday

Morning only Afternoon only After-school onlySchool hours only We are flexible

Wednesday

Morning only Afternoon only After-school onlySchool hours only We are flexible

Thursday

Morning only Afternoon only After-school onlySchool hours only We are flexible

Friday

Morning only Afternoon only After-school onlySchool hours only We are flexible

Do you have a preference for where we see you?

Home visit School / daycare visitOsborne Park Clinic Rooms Mandurah Clinic Rooms Established School-Based Clinics

1st preference

Home visit School / daycare visitOsborne Park Clinic Rooms Mandurah Clinic Rooms Established School-Based Clinics

2nd preference

Home visit School / daycare visitOsborne Park Clinic Rooms Mandurah Clinic Rooms Established School-Based Clinics

Are you interested in online sessions?

Yes - I'd like more information about this optionYes - we would like to see if online sessions would suit usYes - we wish to book an online Lisp Check AssessmentNot at the momentOther

Mealtime Therapy

You indicated you require feeding and/or mealtime therapy. Please specify your concerns below.

I would like support with:

Breastfeeding Bottle feedingStarting Solids Fussy / picky eating Difficulty chewing and/or swallowing Feeding tubes and/or tracheostomyAnxiety about mealtimesSensory ChallengesOther

Has your child had feeding therapy before?

Yes No

Final Notes

Is there any other information that you think we should know about?

Please upload any documentation you would like to include (e.g. NDIS Plan, Medicare Plan, Previous Reports etc.).

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Can we add you to our mailing list for occasional newsletters or update mail outs? (You can unsubscribe at any time)

YesNo

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