Intensive Request Form July 2022

Intensive Request Form July 2022

IMPORTANT: We only have a limited number of guaranteed places. If we are unable to schedule you for one of our guaranteed spots, you will be placed on the wait list and contacted if a spot becomes available.
Caregiver Name *

First Name Last Name
Contact Information
Email *
example@example.com
Phone Number *
Input with no spaces or dashes.
Child's Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

Suburb State

Postcode Country
Child's Information
Child's Date of Birth *

Month Day Year
Child's Gender *

Female Male Nonbinary Other
List any diagnoses your child has: *
List any medications your child currently takes: *

Required Forms
Please complete and upload the Risk Management form from our website: *

Cancel of
Please upload a recent photo of your child (to be stored in their file): *

Cancel of
Has your child been seen at The Sensory Gym® before? *

Yes - my child was seen within the past 12 months (after 1/6/21) Yes - my child was last seen prior to 1/6/21 No
Are you using NDIS funding for this intensive?

Self-Managed NDIS Agency-Managed NDIS Plan-Managed NDIS No/none of the above

New Client Info
Please upload your completed Referral Questionnaire:

Cancel of
Please upload your completed Sensory History Form:

Cancel of
Please upload your completed Preschool or School Questionnaire:

Cancel of
You may upload any additional documents that are relevant (i.e., therapy reports, etc.):

Cancel of
Funding
Are you using NDIS funding for this intensive?

Self-Managed NDIS Agency-Managed NDIS Plan-Managed NDIS No/none of the above

Returning Client Details
Please upload the Previous Client form:

Cancel of
Funding
Are you using NDIS funding for this intensive?

Self-Managed NDIS Agency-Managed NDIS Plan-Managed NDIS No/none of the above

Funding Information
Please upload your child's current NDIS plan.

Cancel of

Cancellation Policy

If you cancel and we are unable to find a replacement for your spot, the following cancellation fees will be charged to either your nominated credit card or your child's NDIS plan (depending on your method of payment. This also includes no-shows and is applicable to all NDIS and non-NDIS clients.

Cancellations less than 20 business days before intensive	$50 cancellation fee
Cancellations less than 10 business days before intensive	Charged 50% of full intensive fee
Cancellations less than 5 business days before intensive	Charged 100% of full intensive fee

NOTE: If any individual sessions are cancelled during the intensive week you will be charged 100% of the fee for that session.

Sign here to indicate you have read and understood the terms of the cancellation policy: *

Clear
Holding Deposit Payment Method
Please note that your card will NOT be debited unless the cancellation policy applies.
Name on Card *
Credit Card Type *
Card Number *
Card Expiration Date (MM/YY) *
Should be Empty:

Intensive Request Form July 2022

Contact Information

Child's Information

Required Forms

New Client Info

Funding

Returning Client Details

Funding

Funding Information

Scheduling Request

Cancellation Policy

Holding Deposit Payment Method