5/1420 Anzac Avenue,
Kallangur
8/164-168 Station Road,
Burpengary
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About
About Us
Our Team
How We Work
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Values
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Services
Occupational Therapy
Speech & Language Therapy
Counselling for Kids
Paediatric Physiotherapist
Allied Health Assistant
Animal-Assisted Therapy
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Get Started
A Bit About You (and Your Child!)
Fill out the form below so that we can start to understand your child and how we can best support your family.
Referral Form
Child's name
Child's D.O.B
Person Making Referral Name
Relationship to the child? Mother, Father, Grandparent, Guardian.
Service Type
Occupational Therapy
Speech and Language Therapy
Counselling
Physiotherapy
Allied Health Assistant
Animal Assisted Therapy
Peer and Group Therapy
Email Address
Phone Number
Address
Child's school, suburb and class
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Diagnosis
Concerns (please give as much detail as possible to help us triage your referral)
Funding
National Disability Insurance Scheme- Plan Managed
National Disability Insurance Scheme- Self Managed
Private
Medicare (only Better Access to Mental Health Care Plans accepted)
Other
Please outline funding here
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To ensure everyone's safety please answer the following questions
Are there any court orders or parenting arrangements we need to aware of?
Does the client have any allergies, chronic illness or medical issues we need to be aware of?
Are there any concerns with having to wait in a busy waiting room?
Does the client have any sensitivities or dislikes we need to be aware of?
Does the client have difficulty finishing or leaving appointments?
Does the client ever abscond (run away) or wander?
Does the client present with unexpected aggressive or violent behaviours?
Allergy to dogs?
Fear of dogs?
Please tell us more about the options selected above
Preferred therapy days and times
Please note after school timeslots are highly sought after. We ask that you consider initially taking an alternative timeslot in the meantime.
What is your preferred location or format for therapy?
Kallangur clinic
Burpengary clinic
Mobile (Limited Availability)
Other
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