Registration Form- Sydney

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

Ethnicity

CONTACT DETAILS

Emergency contact name: *

Mobile Phone *

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

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.

EDUCATIONAL INFO

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

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

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:

Describe any concerns/growth areas regarding your child's development: *

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

Does your child have NDIS 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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