Welcome to Family Connections Sydney!

Should you require Occupational Therapy Services, please complete the information below. By providing detailed information it allows us to better understand and attend to your needs.

Once you complete the form, we will review it and contact you as soon as we can provide services. Depending on your availabilty, we may be able to provide services immediately. If we are unable to provide services immediately, you will be added to our waitlist.

The timeframe in which you may be waiting for services depends on the type of services you require, the complexity of needs, skill set of the Therapist when availability arises and your availability. This makes it difficult for us to predict but rest assured we will do our very best to assist as many families as we can!

Client Details

First Name *

Surname *

DOB *

Address

Suburb *

State *

Postcode *

Phone Number *

Email Address *

Parent/Carer's Name *

Please select the appropriate funding *

Referral Details

How did you hear of Family Connections Sydney? *

Referrer's Details

Were you referred to a specific Therapist within Family Connections Sydney? *

YesNo

If yes, which Therapist were you referred to see?

Services

What services have you been referred for? *

Assessment - Please select:

An Occupational Therapy Assessment HAS been completed in the last 12 months.An Occupational Therapy Assessment HAS NOT been completed in the last 12 months.

Please indicate if you ONLY require an OT assessment and not regular ongoing therapy (as there is a shorter wait time).

If yes, please upload the Occupational Therapy Assessment Report

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Have you received a diagnosis for your child/teenager? (if applicable)

YesNo

If yes, please provide specific details

What difficulties is your child/teenager experiencing? (Please provide as much detail as possible for us to understand your needs).

Availability

Before and after school appointments are in high demand. Please be aware if you are only available at these times the wait time is extensive. Please provide your maximum availability.

Please provide times on each of the days selected that you are available

If we are not able to provide services straight away would you be interested in joining our cancellation list? (This would mean you could be called at short notice for occasional appointments as they come up during the term).

Yes, I am interested in joining the cancellation list.I do not wish to join the cancellation list.

If you have selected yes, you will shortly receive some intake forms to be completed so we have all the information ready for us to be able to offer you occasional appointments at short notice. Please keep an eye on your inbox or junk/spam folder. Once all the documents are received we will add you onto our cancellation list.

If we have the availability, would you be interested in school holiday intensives whilst you wait for regular therapy? (This would include 5 consecutive days of therapy in a week of the school holidays).

Yes, I am interested in school holiday intensivesNo, I am not interested in school holiday intensives

Completed by

Name of client or authorised representative *

To keep our waitlist updated we regularly send correspondence via email requiring you to update us with your availability, therefore please monitor your inbox or junk/spam folders. If you no longer require services please contact us so we can remove you from our waitlist.

If Family Connections Sydney is unable to provide me services straight away I will need to provide them with regular updated availability when I am sent their "Waitlist Availability Update" form. *

I understand that Family Connections Sydney will send me a SMS reminder if they have not received my "Waitlist Availability Update" form within 7 days of the form being emailed. *

I understand if Family Connections Sydney do not receive a response within 14 days of emailing their "Waitlist Availability Update" Form that they will assume that services are no longer required and I will be automatically removed from the waitlist. *

Signed *

Clear

Date *

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