Request for Therapy Services -Please allow 5 to 10 minutes to complete this form- Request For Therapy Services Step 1 of 5 20% Personal details of the person being referredName* First Last Date of Birth* DD slash MM slash YYYY Gender Female Male Email Address* Street Address State / Province / Region ZIP / Postal Code MobileAre you of Aboriginal and/or Torres Strait Islander origin?Please selectYesNoAustralian Residency statusCitizenPermanent ResidenceVisa (provide details)Visa Details Is English the main language at home?YesNoDo you require an interpreter?*Please selectYesNoWhich language is spoken at home?* Parent/Guardian/Person Responsible detailsRelationshipParentGuardianFoster ParentSelfOtherPlease specify Name Email Address Street Address City ZIP / Postal Code MobileIs the person being referred aware of the referral? Yes No If the referral is for a child, are there any Court Orders or Parenting Orders in place? Yes No Please provide details of the arrangementAttach a supporting documentMax. file size: 8 MB.Does the person or Parent/Guardian require an interpreter? Yes No What language? Emergency Contact:* St.Giles requires one emergency contact person (not already listed) for each referral.Relationship*ParentGuardianFoster ParentSelfOtherPlease specify Mobile*Email* I'd like to access support from a therapist for: Please select yes / no for each of the following:Life Skills (Feeding/dressing/toileting/other life skills)*NoYesTell us more:*Movement (Sitting, walking/running, rolling/ crawling, balancing, coordination/clumsiness, drawing/writing)*NoYesTell us more:*Communicating (Talking, listening, understanding and speech, smiling/non-verbal communication)*NoYesTell us more:*Friendships and relationships (Managing/understanding emotions, understanding other peoples’ perspective, playing with others) as expected for age*NoYesTell us more*Learning: (Remembering and practicing new skills, coping with change, pretend play, letters/numbers, attention/concentration)*NoYesTell us more:*Can't find what you're looking for? Enter your request for therapy below:Don't like filling out forms or having trouble with this online form? Call 1300 278 445 and ask to speak to an intake team member who will complete a brief interview by phone. Funding being used to access the serviceFunding being used to access the service NDIS Public Private Health Insurance MAIB Worker's Compensation DVA Self/Other Medicare NDIS Number* Provider* Member Number* Claim Number* Attach a copy of your Letter of Introduction*Max. file size: 8 MB.Attach a copy of your Letter of Introduction*Max. file size: 8 MB.Attach a referral made by your GP or Paediatrician/Specialist outlining the Medicare Service being requested*Max. file size: 8 MB.Do you have an NDIS application pending?please selectYesNo Person making ReferralName* Position/Organisation Address Street Address City State / Province / Region ZIP / Postal Code TelephoneMobileReceive a copy of this referralYour Email Receive a copy of this Email*
