Demo form – Scribble Children's Therapy

Book appointment - NDIS Funded

Your child’s information

Pronouns(Required)

He/Him

She/Her

They/Them

Other

Your child’s DOB(Required)

Child's Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

School / Kinder / Childcare Name(Required)

Grade (if applicable)

Your child’s language spoken at home(Required)

Do you require an interpreter?(Required)

Yes

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

Your child’s interests or favourite toys(Required)

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

Parent/Caregiver 2 Full Name

First Last

Relationship to child

Parent/Caregiver 2 Email

Parent/Caregiver 2 Phone

Services you are interested in

Occupational Therapy

Speech Pathology

Psychology

Art Therapy

Social Groups

What would you like your child to achieve through Occupational Therapy?(Required)

What would you like your child to achieve through Speech Pathology?(Required)

Has the child attended music therapy previously?(Required)

Yes

(The child does not need to have a musical background or know how to play an instrument to engage in music therapy, however, this information will help formulate the program)

Has the child attended music lessons previously?(Required)

Yes

Is your child overstimulated by sounds?(Required)

Yes

Unknown

Does the client display any particular musical aptitude (skills, abilities, etc)?(Required)

Yes

Unknown

What is the child's favourite style of music?

Please describe the style of music that the child enjoys

Are there instruments in which the child is particularly interested?(Required)

For example, guitar, piano, drums/percussion, xylophone

How does the child respond to music?(Required)

For example, dance, sing, move, play instruments, or child does not respond to music

Has the child attended art therapy previously?(Required)

Yes

Has the child attended art classes previously?(Required)

Yes

Do you and/or others have concerns about the child’s self-confidence and self-esteem?(Required)

Yes

Does the child engage in art making at home?(Required)

Yes

Does the client display any particular art aptitude (skills, abilities, etc)?(Required)

Yes

Unknown

Is the child interested in any of the following activities?(Required)

Drawing

Painting

Sculpting

Collages

Does the child experience any of the following?(Required)

Stress

Anxiety

Depression

Physical pain

What would you like the child to achieve through art therapy?

Which clinic are you enquiring about?

Which clinic are you enquiring about(Required)

Caroline Springs

Moonee Ponds (shorter waiting list)

No preference

Please list days and times that would most suit you for ongoing appointments.(Required)

Please provide as many options as possible, so we can contact you when these days/times become available

Is the child able to participate in Telehealth (online) appointments?(Required)

Yes

Unsure

Do you have a preference for any of the following service delivery options?(Required)

Face to face sessions

Telehealth (online therapy)

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

Yes

Unsure

Please list the suburb and frequency of visits required(Required)

Would you be interested in social group sessions with other children?(Required)

Yes

Unsure - I would be interested in trialling it

Social groups are run by a qualified allied health therapist

Type of Funding

Type of funding(Required)

NDIS* (self managed)

NDIS* (plan managed)

Awaiting NDIS funding

Other

Please note we are not NDIS registered, therefore we are unable to service agency managed participants

What is your NDIS number?

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

Child's Development

What does your child require support with?

Is or has the child consulted any of the below health professionals?

Please state the Speech Pathologist's full name and Organisation(Required)

Please state the Occupational Therapist's full name and Organisation(Required)

Please state the Dietitian's full name and Organisation(Required)

Please state the Chiropractor's full name and Organisation(Required)

Please state the Psychologist's full name and Organisation(Required)

Please state the Physiotherapist's full name and Organisation(Required)

Please state the Paediatrician's full name and Organisation(Required)

Please state the Audiologist's full name and Organisation(Required)

Please state the Optometrist's full name and Organisation(Required)

Please state the Orthodontist's full name and Organisation(Required)

Please state the Ear Nose and Throat Specialist's full name and Organisation(Required)

Please state the Play Therapist 's full name and Organisation(Required)

Please state the Music Therapist's full name and Organisation(Required)

Please state the Art Therapist 's full name and Organisation(Required)

Please state the Practitioner's full name and Organisation(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)

Does your child have any hearing loss?(Required)

Yes

Does your child have any vision loss?(Required)

Yes

Are you interested in therapy assistant services?(Required)

Therapy assistants work under the direction of our therapists to deliver one-on-one therapy at the child’s home/school/kindergarten/childcare. Therapy assistant services can be utilised in addition to therapy.

Yes

Who were you referred by? (if applicable)

Can the child communicate verbally?(Required)

Yes

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

Yes

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

Yes

Do you and/or others have concerns about the child’s ability to follow instructions?(Required)

Yes

Do you and/or others have concerns about the child’s ability to make and maintain friendships with others?(Required)

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

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

Yes

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

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

Yes

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

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

Please add any additional information that you would like your therapist or the admin team to be aware of

How did you hear about us?(Required)

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)

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.

Current NDIS Plan Start date(Required)
DD slash MM slash YYYY

Current NDIS Plan End date(Required)
DD slash MM slash YYYY

Consent to Release Information(Required)
Consent to Release Information - During the delivery of allied health services, we may need to discuss certain aspects of your child’s condition and management with other health professionals, doctors, carers, 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.

I agree

I do not agree

Consent to be photographed or videotaped(Required)
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

Waiver agreement for use of sensory spaces(Required)
We may use our sensory spaces to support your child in achieving their goals. The sensory gym is similar to a playground setting, and may involve the same risks (i.e. fall, injury). Please note, your child will be supervised at all times. I will not hold Scribble Children’s Therapy responsible for any injuries or physical harm that my child may experience. I am aware that this is a release of liability and I agree to this of my own free will.

I agree

I do not agree

Fee Schedule

INITIAL CONSULTATION

Clinic-based initial consultation (not including report)

$220

ADDITIONAL ASSESSMENT AFTER INITIAL

Additional assessments can be completed if necessary and if requested by the parent/caregiver. Please discuss the need with your therapist. The time taken to provide services may vary depending on your circumstances. The following is a guide to what will be provided within a service category and how long we anticipate it will take to reach this outcome.

Sensory OT Assessment (Sensory Profile 2)
Summary of how the child’s sensory patterns may be contributing to or creating barriers to performance in daily life. Please note that this assessment does not include goal planning and a full overview of the child’s functional ability.

Approximately 1-2 hours
$193.99 - $387.98

Functional OT Assessment (Vineland-3)
Vineland: The scales are organised using three domains (Communication, Daily Living Skills, and Socialisation) that correspond to the three broad domains of adaptive functioning specified by the American Association on Intellectual and Developmental Disabilities and by DSM-5.

Approximately 1.5-3 hours
$290.99 - $581.97

Speech Pathology Assessments
We provide a variety of formal and informal assessments, including early language assessments, pre-school and school age language assessments, narrative language assessments, speech sound assessments, fluency assessments, social communication assessments, literacy assessments, and Autism assessments.

Please consult your Speech Pathologist for a quote

THERAPY SESSIONS

Clinic-based session (45 minutes direct time, 15 minutes indirect time). Additional time will be charged to the nearest 5-minute by the hourly rate of $193.99

$193.99

ADDITIONAL TRAVEL CHARGES

0 – 15 km round trip

$48.50

16 – 30km round trip

$97

31 – 45km round trip

$145.50

46 – 60 km round trip

$193.99

61 – 75 km round trip

$242.50

76 – 100 km round trip

$291

RESOURCE DEVELOPMENT

Generic visual aids

$5 per A4 sheet laminated

Individualised visual aids or resources

$193.99 hourly rate – pro rata

CANCELLATION POLICY

Cancellations require 48 hours business days notice or a 100% cancellation fee will apply. If your appointment is on a Monday or Tuesday, cancellation must be made 48 hours before the appointment (not including the weekend or public holidays). Please refer to ‘Cancellation Policy and Consent Form’

$193.99

REPORT WRITING (WITHOUT ASSESSMENT)

Please discuss your report writing needs with your therapist. We require a minimum of 6 weeks notice for reports. Reports are charged by the hourly $193.99 rate, depending on time taken to write the report. Reports are released once full payment is made. A quote will be provided to you via our ‘Report Writing Consent and Agreement Form.’ The following is a guide.

NDIS Review Report
This report is provided to support the child’s NDIS contact to understand the child’s support needs. It includes clinical observations, summary of assessments (if completed), and recommendations for the next plan period.

Approximately 2-5 hours
$387.98-$969.95

Equipment/Resource Recommendation Letter
This letter provides Low Cost Low Risk Assistive Technology (resource) recommendations to support the child in their daily life.

Approximately 1.5-2 hours
$290.99-$387.98

Supporting Evidence / Recommendation Report
We provide a range of supporting evidence or recommendation reports according to your child’s needs, including but not limited to, kindergarten/school letters, social community participation recommendation letters, carer support letters. Please consult your Occupational Therapist.

Approximately 1.5-3 hours
$290.99-$581.97

Speech Pathology Assessment Report
This includes formal assessments and informal observations in the following areas: articulation (speech clarity), receptive language (comprehension), expressive language (talking), fluency (stuttering), social communication, play, and functional status.

Approximately 2-4 hours
$387.98-$775.96

Literacy Assessment Report
This includes formal assessment of the child’s oral language (receptive and expressive language) and reading and spelling abilities.

Approximately 2-3 hours
$387.98-$581.97

Assessment Summary
This includes a brief summary of the assessment completed. Please note, a summary report does not include detailed interpretation of assessment results.

Approximately 1.25-1.5 hours
$242.49-$290.99

Discharge Summary
This includes a summary of the child’s therapy goals, brief summary of interventions utilised to target the child’s goals, reason for discharge and further recommendations (if applicable).

Approximately 1-1.5 hours
$193.99-$290.99

AUTISM ASSESSMENT PACKAGE paid in increments

Total Package Cost = $3000 (includes assessment report and 1x travel to child’s setting)

Deposit

$500 taken at time of booking

Parent Interview with Speech Pathologist

$500 due

Sensory Profile Assessment and Interpretation by Occupational Therapist. Results will be added to the final assessment report.

$500 due

One observation session in Child’s Educational or Social Setting by Speech Pathologist

$500 due

Up to four clinic-based assessment and observation sessions

$500 due at last observation session

Parent Feedback Appointment (Optional)

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Assessment Report

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

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Fee Schedule

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