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

What is your child's preferred pronoun?

Child's Date of Birth *

Your Name *

 

Your Relationship to Child *

Best Phone Contact *

Best Email Contact *

Street Address *

Suburb *

Postcode *

Name of your child's school or daycare (if applicable)

Who recommended that you seek support for your child? *

N/A - decided by yourselves (self-referred)Medical professional e.g. GP, child health nurse, ENTFamily / FriendTeacher / SchoolOther

 

How did you hear about Next Challenge specifically? *

Medical Referral Family / FriendTeacher / SchoolPreviously attended Next ChallengePerth Kids HubGoogleOther

 

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

Email address for invoices to be sent:

More information about services required: *Please specify if: (a) there is a limit on the number of the sessions (b) there is a required location for sessions (e.g. school, home) (c) there is an intended frequency for sessions (e.g. weekly, fortnightly, monthly)

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)

**Services wont be able to commence for NDIS Plan-Managed participants until a plan manager has been allocated.

How can we help?

What type of service are you looking for? *

Speech PathologyFeeding 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? (please specify if you have a preference for diagnostic terms e.g. Autistic) *

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? (N.B. After school appointments are very popular, if this is your only availability it may prolong the wait for services. Your flexibility will assist your child in being seen sooner)

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

If you have different availability for an initial session compared to ongoing therapy, please detail this here:

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

You may decide you would like to attend the first appointment on your own, without your child present. Or you may choose to have the first half of the initial appointment as a phone call between the therapist and yourself. Please let our support team know when they call to book in a session for your child and they can discuss the options with you. 

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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