OCCUPATIONAL THERAPYMEDICARE (MHCP) CLIENT INTAKE FORMIf you have any questions, please feel free to contact us. Client Information Client Full Name * First Name Last Name Preferred Name D.O.B Age Preferred Pronoun Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone Email Guardian Information Guardian Full Name First Name Last Name Phone Email Guardian D.O.B Relationship to Client Preferred Contact for Client * Client Guardian Other Preferred Contact Method * Text Call Email If you selected 'Other', please provide details of contact Name, relationship to client, email, phone and other information you think we would find useful. Medicare Mental Health Care Plan Information Referring Clinician's Name * Referring Clinician's Practice * Medicare Number * Expiry * Client IRN * Guardian IRN *please only provide if client is under guardian's medicare Service Type Services Required Assessments Treatment / Therapy Main Reason Autism / ASD ADHD Anxiety Behaviour Difficulties Developmental Delays Dyslexia Emotionally Sensitive Executive Functions Intellectual Learning Difficulties Neuro-psychological Play Time Skills Poor Handwriting Social Sensory-Processing Self-Care Difficulties Further Information Other Services Engaged Please list any other services you are engaged in and the name of the practice. Thank you!
