Demo form – Scribble Children's Therapy

Book Appointment Form 2024

Phone

This field is for validation purposes and should be left unchanged.

Your child’s information

Pronouns(Required)

He/Him

She/Her

They/Them

Your child’s DOB(Required)

Child's Name(Required)

First Last

Child's Home Address(Required)

Please include suburb. This allows us to identify the closest clinic.

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School / Kinder / Childcare Name

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Grade (if applicable)

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Your child’s language spoken at home(Required)

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Do you require an interpreter?(Required)

Yes

Please note that unfortunately we do not currently have access to on-site interpreting services.

Parent/Caregiver 1 Information

Parent/Caregiver 1 Full Name(Required)

First Last

Relationship to child(Required)

Parent/Caregiver 1 Email(Required)

Parent/Caregiver 1 Phone number(Required)

Parent/Caregiver 2 Information

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Parent/Caregiver 2 Full Name

First Last

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Relationship to child

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Parent/Caregiver 2 Email

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Parent/Caregiver 2 Phone

Services you are interested in(Required)

Please select all services you are wishing to book.

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Preferred appointment day (parent only appointments)

Monday

Tuesday

Wednesday

Thursday

Friday

In order to commence services, you must attend two parent-only appointments (initial consultation and service planning session). You may choose more than one option as this will increase the likelihood of securing a suitable appointment.

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Preferred appointment start time (parent only appointments)

Morning 8:15am (Wed, Fri only)

Morning 9:15am (Mon, Tues, Thurs only)

Mid morning 10:00am (Wed, Fri only)

Mid morning 11:00am (Mon, Tues, Thurs only)

Afternoon 1:15pm (Wed, Fri only)

Afternoon 2:00pm (Mon, Tues, Thurs only)

Afternoon 2:45pm (Wed, Fri only)

Afternoon 3:45pm (Mon, Tues, Thurs only)

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Preferred appointment day (ongoing appointments with child present)

Monday

Tuesday

Wednesday

Thursday

Friday

You may choose more than one option as this will increase the likelihood of securing a suitable appointment.

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Preferred appointment start time (ongoing appointments with child present)

Morning 8:15am (Wed, Fri only)

Morning 9:15am (Mon, Tues, Thurs only)

Mid morning 10:00am (Wed, Fri only)

Mid morning 11:00am (Mon, Tues, Thurs only)

Afternoon 1:15pm (Wed, Fri only)

Afternoon 2:00pm (Mon, Tues, Thurs only)

Afternoon 2:45pm (Wed, Fri only)

Afternoon 3:45pm (Mon, Tues, Thurs only)

Please keep in mind after school slots are in high demand and less likely to be available on an ongoing basis. You may choose more than one option as this will increase the likelihood of securing a suitable appointment.

Which clinic are you enquiring about(Required)

Caroline Springs

Moonee Ponds

Craigieburn

Werribee

No preference

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Do you require community visits to the child’s home, school, or kindergarten?

Yes

Unsure

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Please list the suburb and frequency of visits required

Type of funding(Required)

NDIS* (self managed)

NDIS* (plan managed)

Awaiting NDIS funding

Medicare GP Plan

Private - No Funding

Please note, if you have NDIS funding, we can service NDIS self managed and NDIS plan managed participants. If your plan is managed by the NDIA (sometimes referred to as Agency-managed), you will need to engage with alternative NDIS registered providers.

What is your NDIS number?(Required)

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Current NDIS Plan Start date

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Current NDIS Plan End date

What is the full name of your plan management provider?(Required)

Does your child have a diagnosis?(Required)

Yes

Unsure

Please list the diagnosis and the year that the child was identified to have the diagnosis(Required)

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Does your child have any hearing loss?(Required)

Yes

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Does your child have any vision loss?(Required)

Yes

Please list your preferred appointment days/times

Please include days, time and frequency

Describe your child's communication skills.(Required)

Non-speaking

Gestures

Single words/short phrases

Sentences

Communication tools i.e. Proloquo2Go, communication board

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Do you and/or others have concerns about the child’s ability to produce speech sounds?

Yes

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Do you and/or others have concerns about the child’s ability to be understood by others?

Yes

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Have you and/or others noticed differences in the child’s play?

Yes

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Are you and/or others concerned about the child’s reading, spelling or understanding of written text?

Yes

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Have you and/or others noticed differences in the child’s behaviour?

Yes

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Have you and/or others noticed differences in the child’s ability to attend or concentrate on tasks?

Yes

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Do you and/or others have concerns about the child’s stuttering or ability to speak fluently?

Yes

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Do you and/or others have concerns about the child's fine motor skills?

Yes

For example, the way that they hold a pencil, draw, eat with cutlery

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Do you and/or others have concerns about the child’s gross motor skills?

Yes

For example, their running, jumping, ability to participate in sport

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Do you and/or others have concerns about the child’s self care skills?

Yes

For example, their ability to dress, feed or brush their teeth

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Do you and/or others have concerns about the child’s ability to regulate their emotions?

Yes

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Do you and/or others have concerns about the child’s ability to express their feelings?

Yes

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Does your child tend to hit, bite or hurt others when they are dysregulated?

Yes

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Do you and/or others have concerns about the child’s ability to concentrate on tasks?

Yes

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Are there any precautions that should be taken with the child, in regards to their personal safety?

Yes

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How did you hear about us?

Please note, we do not provide intervention in the following areas:

- Behaviour therapy/Compliance-based therapy
- Home modifications
- Assistive technology
- Voice disorders
- Swallowing/feeding
- Stuttering over the age of 6
- Childhood Apraxia of Speech (CAS)

Please provide a detailed explanation of the support or supports your child requires, so that it can be provided to your therapist.(Required)

Please tick boxes where your child requires support
Self-care (Example: Toileting, sleep, dressing, eating, washing)
Emotional regulation
Cognition
Social navigation
Fine motor
Gross motor
Communication
Select all that apply.

Upload your files
Please upload relevant reports from health professionals, assessments and NDIS Plan/Medicare referral

Drop files here or

Max. file size: 10 MB.

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Consent to Release Information
Consent to Release Information - During the delivery of allied health services, we may need to discuss certain aspects of your child’s therapy plan with other health professionals, doctors, teachers or other parties involved in your child’s care. Correspondence may occur face to face, over the telephone, via mail or email. By signing below, you are providing consent for us to contact relevant parties involved in your child’s therapy activities. I hereby give Scribble Children’s Therapy permission to release information regarding my child. Please note, if you are plan managed, we will need to liaise directly with your plan manager for invoicing and billing purposes.

I agree

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Card on file policy
Scribble Children’s Therapy requires all clients to provide debit/credit card information which will be kept on file. Your private information is securely stored and encrypted in our practice management system. This means, once initially entered and captured, your card details are not visible to anybody within the clinic. Scribble Children’s Therapy reserves the right to use your debit/credit card information for charges incurred for direct and indirect services delivered to you, outstanding account balances, cancellations, missed appointments or outstanding plan management invoices. It is your responsibility to ensure that there are sufficient cleared funds in the nominated debit/credit card by, and at all times on, the due date of the payment to enable the charge to be processed. By selecting "I agree", you acknowledge and agree that sufficient funds will remain in the account/card and that if there are insufficient funds available when the charges are attempted, you agree that you will be responsible for any fees and charges that may be charged by your Financial Institution or dishonour fees that may be charged by Scribble Children’s Therapy. If the automatic authorisation date falls on a weekend or public holiday the charge may be initiated on the next working day. If your card on file is charged, you will be provided with a receipt.

I agree

Policies(Required)
I acknowledge that I have read and understood the Terms and Conditions and Privacy Policy.
These policies are accessible via the footer of this website.

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Consent to be photographed or videotaped
We may take photos and videos of your child during therapy to record their progress. We will not use your child’s photos for social media and/or advertising. Please advise us immediately if you do not want your child to be photographed or videotaped. I agree to my child being photographed or videotaped for assessment and/or therapy purposes.

I agree

I do not agree

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Date
MM slash DD slash YYYY

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Date
MM slash DD slash YYYY

Book Appointment Form 2024

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