Waitlist is open for Killarney Vale & Toukley Locations ONLY.

Coastwide Therapy Self Referral Form

Client Details

First Name*

Last Name*

DOB

Gender

Male

Female

Non-Binary

Prefer not to say

Email*

Phone*

Street Address*

Suburb*

Postcode*

School Attended

Year / Class

NDIS Funding

Yes

NDIS Number

Plan Start Date

Plan End Date

How is the Plan Managed

NDIA Managed

Self Managed

Plan Managed

Plan Manager Name (if applicable)

DETAILS OF PARENT / CARER / GUARDIAN (AUTHORITY TO SIGN)

First Name*

Last Name*

Relationship to client*

Contact Number*

Email*

Living Arrangement

With Family

Out of Home Care / Foster Placement

Group Home

Supported Accommodation

Independent

Living Arrangement (fill if the living arrangement is not listed above)

Is a Parenting Order in place

Yes

CLIENT’S ADDITONAL INFORMATION

Relevant Medical Concerns (select all that apply)

Food Allergies

Anaphylaxis

Seizures

Asthma

Hearing Impaired

Vision Impaired

Relevant Medical Concerns (fill if there is another medical concern)

How does the client communicate (select all that apply)

Verbal

Non-Speaking

Sign

Gestures

Assistive Technology

Diagnosis

Do you require mobility aids to walk e.g., wheelchair / walking frame

Yes

Do you require ramp access

Yes

Medication(s)

Country of Birth

Language(s) Spoken at Home

Do you identify as Aboriginal or Torres Strait Islander

Yes

Religion / Culture / Custom

Risk to self or others (select all that apply)

Absconding

Aggression

Violence

Risk to self or others (fill if there is another risk not listed above)

Current Behaviour Support Plan in place

Yes

Have you accessed Occupational Therapy previously?

Yes

Approx last date of service

Other Providers:

Main Areas of Concern (only fill if you chose Other)

Background Information / Reason for referral and any urgency requests (Please explain the goals to be achieved)*

Please verify your request*

Killarney Vale - 1/13 Robertson Road , Killarney Vale 2261

Toukley- 1/44 Victoria Ave, Toukley

Woy Woy - 12, 26-30 Railway Street, Level 1, Clock Tower Building, Woy Woy

Wyoming - 1B, Unit 1, 470 Pacific Highway, Wyoming 2250

Phone: 02 4388 1110 for more information

Terms & Conditions