Intake Information

Thank you for taking the time to complete this form. The information you provide helps me prepare thoroughly so the therapeutic support I offer you is aligned with your individual needs. Please complete all sections that are relevant to you.

What happens next:
Once you’ve submitted this form, you’ll receive an email with two important links:

One to my online calendar so you can book your sessions at a time that suits you
One to the service agreement (required before your appointment can be confirmed)

If you have any questions in the meantime, feel free to reach out to Michelle at admin@beyouot.com - she’ll be happy to assist.

Date of referral *

Client Details

First Name *

Last Name *

Date of Birth *

Pronouns

She|her|hersHe|him|hisThey|them|theirsOther

Address *Please include the postcode

Mobile Number *

Email *

Neurotype Self-identification is a valid and meaningful way to understand your neurotype. You don’t need a formal diagnosis to recognise patterns in how you think, feel and engage with the world. If you self-identify as autistic for example, even without a formal diagnosis, this is still a valid and recognised neurotype.

Medical Diagnoses

Services Requested

All services are delivered via telehealth using Zoom. To support accurate and efficient clinical documentation, I use Heidi Health. By completing this intake form, you acknowledge and agree to the use of Zoom for sessions and Heidi Health for note-taking.

Please tick the services you'd like: *

Occupational Therapy sessionsContribution to an autism identification assessmentNDIS support needs assessment and reportLife coaching sessionsEmotional freedom techniques (EFT) sessions

Funding Information

Please note how you'll be funding occupational therapy: *

Privately payingClaiming on my private health insuranceClaiming a Medicare rebate Using NDIS funding

Additional Information for NDIS Participants

NDIS Number

How is your 'improved daily living' funding managed?

Agency ManagedPlan ManagedSelf-Managed

Plan Manager Name (if applicable)

Plan Manager Email (if applicable)

Current goals as stated on the client's current NDIS Plan

Provision of Information

You're welcome to share any other information you think is important for me to know at this stage. Please feel free to share this in as much detail as feels right for you.

Are there any documents you'd like to share?

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Examples: previous reports, medical/allied health letters or your NDIS plan (if you have one).

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