Children's Therapy Service Referral Form

Details of child

Surname *

First Name *

Address *

Postcode *

Date of birth (dd/mm/yyyy) *

Gender *

Australian Residency Status *

Permanent

Temporary

OtherOther

Current school or child care (or write not applicable) *

Details of parents(s) / guardian(s)

Name of parent/guardian 1 *

Parent/guardian 1 address *

Same as child's

Different address

Address

Post code

Name of parent/guardian 2 (or not applicable) *

Parent/guardian 2 address

Same as child's

Different address

Address

Post code

Primary phone number *

Parent/guardian 2 phone number (or same as primary) *

Email address *

Reason for referral

Please list any diagnoses, disability or areas of concern *

Please attach copies of diagnostic reports (or other relevant information)

Maximum file size: 10MB

Attach up to three PDF or Word documents. Maximum upload size is 10 Mb.

Type of therapy requested

Dog-Assisted Therapy

Occupational Therapy

Physiotherapy

Speech Pathology

What interests you in Dog-Assisted Therapy? How do you feel this service could help your child achieve their therapy goals?

Does your child engage in any behaviours that may compromise the safety of our therapy dog?

Yes

No

Please provide details

Available funding *

NDIS Participant Number

Name of NDIS Plan Manager

How did you find out about Kites Children’s Therapy? * How did you find out about Kites Children’s Therapy?

Contact details of Referrer

Complete this section only if the referrer is not the parent

Name

Agency

Phone number

Email address

Declaration *

I confirm that I have the parent/guardian’s permission to make this referral.

Dog-Assisted Occupational Therapy

Kites Referral Form

Details of child

Details of parents(s) / guardian(s)

Reason for referral

Contact details of Referrer