Thank you for requesting an appointment at our Osborne Park Clinic

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 Family / FriendTeacher / SchoolPreviously attended Next ChallengeGoogleOther

 

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 *

Peter Carnley Anglican Community School (Wellard Campus)Peter Carnley Anglican Community School (Calista Campus)Regent College (Term 1, 2024)Other

What school does your child attend? *Please note, school-based therapy will incur a travel charge

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

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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Funding Types

How will you be accessing our Services? *

Private Medicare Chronic Disease Management Plan (aka CDMP)NDIS Self Managed NDIS Plan Managed NDIS Agency Managed Not sure

Next Challenge is not an NDIA Registered Provider. Unfortunately, this means we cannot provide services to agency-managed clients under the NDIS.  

You can use the Provider Finder Tool on the NDIS website to find an NDIA Registered Provider near you.

Please upload or email us a copy of your Medicare Chronic Disease Management Plan.

We will contact you to discuss your funding options.

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

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 TherapyPhysiotherapyWe are not sure at this stage and would like your help with this

Does your child have a diagnosed developmental delay or disability?

YesNo Not yet - we are working with a medical team

What diagnosis/diagnoses does your child have? *

What diagnosis are you currently investigating for your child? *

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?

Osborne Park Clinic Home VisitsSchool Visits Daycare Visits

1st preference

Osborne Park Clinic Home VisitsSchool Visits Daycare Visits

2nd preference

Osborne Park Clinic Home VisitsSchool Visits Daycare Visits

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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Next Challenge offer a range of group therapy services for parents and children. Are you interested in accessing group therapy? *

YesNo

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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