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About
Services
Intensive Therapy Program
Occupational Therapy
Physiotherapy
Exercise Physiology
Hydrotherapy
Speech and Language Therapy
Blog
Media
Contact
Course
Call us today
About
Services
Intensive Therapy Program
Occupational Therapy
Physiotherapy
Exercise Physiology
Hydrotherapy
Speech and Language Therapy
Blog
Media
Contact
Course
Call us today
Centre of Movement Intake Form
Desired Clinic Location
(Required)
Please Select
Australia – Burleigh Heads
New Zealand – Rotorua
New Zealand – Christchurch
Program of Interest (click all that apply):
(Required)
Intensive Therapy – Three Weeks
Intensive Therapy – One Week
Regular Therapy
Other
Other
How did you hear about COM
(Required)
Please Select
Word of Mouth
Instagram
Facebook
Google
Health practitioner
Case Manager
News
Other
how did you hear about COM other
Availability
When would you like to attend the Centre of Movement?
(Required)
What time/s are best for your child to engage in therapy?
(Required)
Will you need a report following this intensive?
(Required)
Please Select
Yes
No
N/A
How will your child’s therapy be funded?
Please Select
NDIS – National Disability Insurance Scheme
MOH – Ministry of Health
ACC – Accident Compensation Corporation
Private
Other
Parent/Caregiver Details
First Name
(Required)
Last Name
(Required)
Address
(Required)
Street Address
Street Address Line 2
Street Address Line 2
City / Town / Suburb
(Required)
City / Town / Suburb
State / District
(Required)
State / District
Post Code
(Required)
Post Code
Country
(Required)
Country
Contact Information
Phone Number
(Required)
Include country and area code
Primary Email Address
(Required)
example@example.com
Additional Parent/Caregiver Details
First Name
Last Name
Phone Number
Include country and area code
Email Address
example@example.com
Primary Language
Do you have a need for interpretation services?
Yes
No
Child's Details
First Name
(Required)
Last Name
(Required)
Date of Birth
(Required)
MM slash DD slash YYYY
Date
Gender
(Required)
Male
Female
Prefer not to answer
Medical History
Primary Diagnosis
Secondary Diagnosis
Date of Diagnosis
MM slash DD slash YYYY
My child presents with hearing concerns.
(Required)
Yes
No
My child presents with vision concerns.
(Required)
Yes
No
My child presents with fatigue concerns.
(Required)
Yes
No
Medications
Current Weight
(Required)
Current Height
(Required)
Has your child previously had or currently have a heart condition?
(Required)
Yes
No
A close relative who has died suddenly from a heart condition before the age of 50?
(Required)
Yes
No
Uncontrolled epilepsy or seizures/convulsions?
(Required)
Yes
No
Not Identified
Does your child have a seizure management plan?
(Required)
Yes
No
Fainting or dizzy spells with physical activity/exercise?
(Required)
Yes
No
Not Identified
Diabetes?
(Required)
Yes
No
Not Identified
An asthma attack requiring immediate medical attention at any time over the last 12 months?
(Required)
Yes
No
Not Identified
Anaphylactic reactions or allergies?
(Required)
Yes
No
Not Identified
Recent surgery or hospitalisations?
(Required)
Yes
No
If yes, please provide details
When was the date of your child's last hip/pelvic x-ray?
MM slash DD slash YYYY
Date
Right Hip: Percentage Subluxation
Left Hip: Percentage Subluxation
Has your child now or ever had a diagnosis of decreased bone density?
(Required)
Yes
No
If yes, please detail more about your child's low bone density
Has your child now or ever had a diagnosis or concerns of scoliosis?
(Required)
Yes
No
If yes, please detail more about your child's scoliosis degree
Has your child ever had a fracture?
(Required)
Yes
No
My child currently receives (click all that apply):
Feeding Therapy
Occupational Therapy
Physiotherapy
Exercise Physiology
Speech Therapy
No therapy at this time
Please list any other therapies your child participates in, including any intensive programs.
Developmental Skills/Goals
What do you and your child hope to work towards during therapy?
Add
Remove
Gross Motor Skills
Just getting started
Making progress
With equipment
Independent
Head control
Roll
Reach
Sit
Crawl
Pull to Stand
Stand
Take Steps
Walk
Run/Jump/Hop
Coordination
Gross Motor Skills Comments or Goals
Fine Motor/Activity of Daily Living Skills:
Exploring
Gaining control
With assistance
Independent
Hold object with both hands
Hold objects functionally
Brings objects to mouth
Uses hands to play
Helps with dressing
Fine Motor/ADL Skills Comments and Goals
Cognition & Learning
Still developing
Needs support
Almost there
Confident & independant
Attention & focus
Emotional regulation
Behavioral control
Language & communication
Academic learning
If there are specific goals related to cognition and learning, feel free to include them here.
Sensory Processing Comments and Concerns.
Include here any information that may be helpful for us to better support your child’s sensory needs. Please detail any goals that pertain to sensory processing.
New Zealand Only
The following questions only need to be answered by our NZ clients
Would you like speech therapy to be included in your intensive?
Yes
No
Is there any other information that you would like us to know?
We’re Excited to Have You On Board
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