form pageOccupational therapy

Client First name

Client Last name

Client Gender and pronouns

Parent/ Carer Email

Parent/ Carer name, if participant under 18

Parent/ Carer's relationship to child

Participant or Parent/ Carer Phone

Participant or Parent/ Carer Address

Participant's birthdate

Day

Month

Year

Participant's NDIS number

Email to send invoices to.

Payment information: How will you pay? NDIS, Private Payment, Private Health Fund, Medicare, Other.

NDIS plan start and end date

Please upload any supporting documents.

File upload

Supporting Document Review

If you provide supporting documents (e.g., OT reports, Early Childhood Support plans), our staff may need to review them prior to the session. This review is billed at a pro-rated rate of $193.99 per hour, approximately $145.50 for a 45-minute review.

Has the participant spent any time around horses before?

Yes

No

If yes, please describe

Any fears or allergies we should be aware of?

Does the participant have any diagnosis or suspected condition? Please detail.

Other supports currently involved

Goals and hopes

Any additional information.

I confirm that I have read, understood, and agree to the Alkira Adina Equestrian Service Agreement / Terms and Conditions, including the cancellation policy, safety requirements, and all session guidelines.Terms and Conditions

I confirm that I have read and understood the Alkira Adina Equestrian Waiver via the link provided, and I acknowledge the risks associated with equine activities. By signing this form, I agree to follow all safety instructions and guidelines provided by staff.Waiver

I acknowledge that the hourly rate is $193.99. Sessions are billed as 50 minutes of session time and 20 minutes of non face to face time. This totals $226.32 per session.

Report Guide Acknowledgement:

Brief progress summary: $400
Standard functional / support report: $600
Comprehensive / multiple-document / time-sensitive report: $750–$850

Date

Day

Month

Year

Signature (must be over 18)

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Name and relationship if signing on behalf of a child under 18.

Occupational Therapy Information and Intake Form