Clear drawing

Client Intake Form


Participants details

Participants Contact details

Complete if address is different from the above.

Main Contact:

Carer/Family Details :

Please provide First and Last name.

If you have answered yes. Please provider diagnosis.
If you have selected other please add in the comment section.
If you have selected other please provide details in the comment section below.
Please provide school / day care name if you have selected this as an option for visits.
Please add time preference in the comment section below. We do our best to schedule your preferred times where we can, however this is not always guaranteed.
Please provide details of preferred time if you did not select anytime in the comments below. Please note as this may be your preference we cannot guarantee this will be available at the time of booking, but try to accommodate where possible.

Self Managed - Payment is require on the day of appointment. This can be made in person at reception, via phone, or processed via our Medipass System. Further details will be discussed when contacted to schedule intial appointment

NDIA - Participants NDIS Number to be provided for Optimum Movement to request payment. 

Plan Managed - Participants plan Manager details are to be provide. (Email address for invoices and Coordinator and best contact Number to be provided.)

Costs: Further details will be discussed at time of call.

  • Initial appointment is scheduled for 2 x 1hour sessions - $193.99 per/hour (Total cost for initial $387.98)

  • Initial appointment scheduled with senior OT for 2 x 1hour sessions - $200 per/hour (Total cost for intial $400.00)

  • Regular Cost for 1 hour therapy session - $193.99

  • Regular Cost for 1 hour therapy with Senior OT - $200.00

  • Mobile Costs - dependent on location. $16.16per 5 minutes

Interests, physical/ Cultural/ belief-based requirements. Travel cost to be discussed at the time of scheduling mobile appointment if required.
Draw signature|Type signatureClear

Referral Details