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Client information (Child)

Date*

Full Name*

Address*

Sex*

Date of birth*

Funding

Funding type*

NDIS number*

Email address to send Invoices to

Plan Manager or Company Contact Information

Name, Email, Phone

Parent/Guardian Contact Details

1 Full Name*

1 Contact Number*

1 Relationship*

1 Email*

2 Full Name*

2 Contact Number*

2 Relationship*

2 Email*

Emergency Contact Details

1 Full Name*

1 Contact Number*

1 Relationship*

2 Full Name*

2 Contact Number*

2 Relationship*

Consent

Do you give Radiant Holistic Care Staff consent to:*

Perform developmental assessments

Provide relevant copies of information to external medical professionals

Discuss your child's development and personal information with their school or preschool

Document information about your child's sessions and record on Cliniko

Take photographs of your child for professional purposes only

In the case of an emergency, do you give permission for Radiant Holistic Care staff to:*

Call an ambulance

Administer medication/s

Are there any court orders in place?*

Yes

No

If yes, please provide details of the court orders and a copy *

Does your child have any allergies or asthma?*

Yes

No

If yes, please provide information about their asthma or allergy

Does your child have any other medical conditions or information that we should be aware of

Medical History

Detail any current or previous medical conditions, diagnosis and family history *

Reason for gaining Occupational Therapy and any goals for your child *

Interests

What are your child's current interests so we are able to provide personalised therapy plans

What are your child's dislikes, or any cultural sensitivities we can respect

Any further information you would like us to be aware of

Signature

I acknowledge that the information in this form has been completed accurately

Full Name *

Signature*

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Date *

Best availability for our team to contact you

Phone: 02 4072 2020 Mobile: 0427 394 396 Email: info@radiantholisticcare.com.au

ABN: 11677732982

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