Registration Form Melbourne

New Client Registration Form

CLIENT DETAILS (child's details)

First Name

Last Name

Preferred Name

Date of Birth

Child's sex

MaleFemaleIntersexPrefer not to say

Leapfrog is LGBTQIA+ inclusive, and want to respect the choices of both you and your child. If your child's gender identity or pronouns differ from those commonly used with their birth sex, please indicate their preferred identity/pronouns below:

English is a Second Language *

YesNo

Primary Language: *

Ethnicity

We have an ST who speaks Cantonese fluently. Would you prefer to have ST sessions in Cantonese?

YesNo

We have an ST fluent in Cantonese and an OT fluent in Mandarin. If possible, would you prefer to have sessions in one of those languages?

Yes - CantoneseYes - MandarinNo - English is fine

We have an OT who speaks Mandarin fluently. Would you prefer to have OT sessions in Mandarin?

YesNo

We do not currently have any staff fluent in that primary language. If possible, would you like us to engage interpretation services to assist with the therapeutic relationship?

YesNo

Are you located in Melbourne or Sydney? *

MelbourneSydney

CONTACT DETAILS

Parent/Carer Name *

Parent/Carer Mobile Phone *

Parent/Carer Email *

Emergency contact name (to be contacted if parent not available)

Emergency Contact Mobile

Emergency Contact Email

Home address *

Street *

Suburb

State *

Postcode *

Does your child live at this address with both parents together? *

YesNo

Are there any court orders in place?

YesNo

We require all children under 14 years to be collected from the clinic by an authorised adult. If your child is 14 years or older, do you consent to them leaving the clinic unaccompanied?

YesNo

Please provide any additional information regarding your child's home life you feel is relevant. i.e., detail of court orders, limited contact with a parent etc. Please also note that if your family circumstances change throughout your time with Leapfrog, it is your responsibility to notify the team here so that we can continue to deliver the highest standard of service to your child.

SEPARATED PARENTS/FAMILIES POLICY

Our Requirements and Expectations

1. It is our expectation that separated parents work together respectfully and cooperatively regarding the care of their child.  

2. It is the parents’ obligation to provide us a copy of any relevant legal documents or court order prior to therapy commencement. 

3. Either parent or legal guardian can:

schedule an appointment with their child
be present at their appointment
and/or request a copy of the child’s reports or treatment notes

UNLESS there is a court order restricting their involvement in their child’s care. If this is the case, please ensure you provide these court orders at your first visit to the clinic.

4. If an appointment is made by one parent, it is the responsibility of this parent to inform the other parent, invite them to attend, and/or provide feedback to them.

5. Assessment reports will be sent to the parent(s) who attended the assessment appointment as standard. If only one parent attends, it is their responsibility to forward the report to the other parent. 

6. We do not have the capacity to provide separate intakes or feedback appointments for each parent but welcome both parents to attend appointments and will provide copies of correspondence to each parent if specifically requested.

7. Leapfrog Therapy will not accept part payment of therapy invoices.  If there is legal agreement that requires one parent to pay all or part of the treatment costs, one parent will need to provide credit card details and seek reimbursement directly from the other parent.

8. Where there is significant conflict between separated parents, we reserve the right to request court orders, obtain signed consent from both parents prior to any service provision, or limit our services until the dispute has been resolved.  If necessary, we may discharge a family from services if the conflict is disruptive to the clinic or impedes the care of the child.

9. We do not take referrals where the purpose of the assessment is to generate information for legal decision making around custody issues of parental separation.

Signing this document acknowledges you have read the above policy and agree to abide by this agreement: *

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EDUCATIONAL INFO

Our therapists work closely with teachers. The more contact details we have for them the easier this is!

My child's school/ Kindergarten/daycare (NOTE if yours is not listed, please let us know their school below)

Note: Lauriston clients receive a $15 per session discount on all ELC/school based sessions.

Name of school/kindergarten/daycare

If kinder/daycare, what days of the week do they attend?

Teacher Name and Year Level

Is your child's school a specialist school?

YesNo

SUPPORT NEEDS

Services required

I know the specific service my child requires:

The following is included in the costs of the Handwriting Assessment and Accommodations Clinic at Leapfrog Therapy. The total cost for this assessment is $670.00, and is payable in full on the day of your initial appoint. The breakdown of that cost is as follows:

Initial 75-Minute Assessment Clinic Booking:

15-minute Intake: This portion of the assessment allows the assessing therapist to obtain some background information about your child, including a detailed history of any writing struggles and a discussion around any concerns that you/they/their teacher have.

This can be parent only, or can involve your child based on your/their personal preference. If they don't wish to take part, there is a waitroom facility they can use.

60-minute Child Assessment:A thorough assessment of your child’s handwriting will be conducted through one or more standardized assessments. This will be very thorough to understand your child’s needs and supports required. During this time, we will ask you to wait in our waitroom, and potentially complete a few more questionnaires about your child (if required).

Subsequent Sessions/Outputs:
15-minute Feedback (telehealth): This session is used to provide you and the young person the results of

the assessments completed, and answer any questions. This session time should be confirmed with our Admin Support team before you leave the Assessment Clinic appointment. The standard 15-minute feedback cost is included in the initial $670.00 payment.

Occasionally, where results are more complex or warrant further discussion, we may extend the feedback session by a further 15 minutes. If that is required, the admin team will notify you in advance, and an additional $51.25 charge will apply.

Summary Report*: A written summary of the young person's assessment will be provided approximately a week after the parent feedbacksession, unless otherwise discussed. The summary report is included in the initial $670.00 payment (no additional charge applies.)

The next Little Leapfrog Supported Playgroup will commence in Term 3, 2026.

The Little Leapfrogs Fee Schedule is currently being updated, and will be provided by 1.6.26.

Submission of this form will secure your child's place in a group.

NB: There is a minimum of 3 children required for the playgroup to go ahead.

Describe any concerns/growth areas regarding your child's development. If registering for the Drop In Clinic, what are you requiring support with? *

Is your child aware of their diagnosis?

YesNo

Please provide additional information regarding your child's diagnosis. If your child has been identified with Autism, please describe their level. If your child has a diagnosis not listed above, please provide more information.

Leapfrog is committed to working collaboratively with your other services to best support your child. Please indicate any other Allied Health professions your child currently engages with:

For any services you selected above, please indicate here the frequency of your child's engagement with those services (i.e. weekly. fortnightly, monthly, consultative, etc.):

Does your child currently engage in ABA therapy? If yes, how often?

To your knowledge, has your child ever displayed 'at-risk' emotional wellbeing behaviours to self/others (e.g. expressed feelings of low mood/hopelessness/self-harm)?

YesNo

To your knowledge, has your child ever demonstrated any challenging behaviours (e.g. emotional meltdowns, physical aggression, tendency to abscond) which might impact their ability to engage with O.T. or Speech Therapy?

YesNo

REFERRAL AREAS

FUNDING

Our fee schedule can be found here: CLICK HERE

I confirm that I have read the attached fee schedule and are willing to proceed with registration based on this. *

SIGNATURE

Patient/ Guardian Signature

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