Client Intake Therapy Services

I understand that applications for therapy services will only be accepted for the current vacancies listed above and that AASS does not hold a waitlist for Therapy services.

Time Selection: Applications that don't reflect the available times listed above will be rejected.

Client: First Name

Client: Last Name

Clients Details

Clients Date of Birth

Client Contact Number

Client Email Address

Gender

Male

Female

Other

Clients Country of Birth

Languages Spoken at Home

Is the Client of Aboriginal or Torres Strait Islander Decent

Client Address

Address Line 1

City

State

Post Code

Country

Name of School / Preschool Client Attends

Year Attending

Funding Source

NDIS Management

Self Managed

Plan Managed

Agency Managed

Plan Managers First Name

Plan Managers Last Name

Plan Managers Email

Plan Managers Phone/Mobile

NDIS Plan.

Please upload your NDIS Plan to assist us with goal setting

Optional - Upload your NDIS Plan here

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Clients NDIS Number

Does the Client have a formal ASD diagnosis?

How does the Client Communicate?

Clients Medical Information

AUTISM ADVISORY AND SUPPORT SERVICE

Client Intake Form for Therapy Services

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