Aquatic Therapy Referral Form

This program is most suited to children between the ages of 3 – 14.

Sessions run at Clovercrest on Wednesdays and Plympton on Tuesdays.

Please fill in the below referral form for the Aquatic Therapy Program. This will be directly forwarded to our team, who will be in contact with you.

Client Information

Client name *

Preferred Name (if different)

Date of birth *

Pronoun

he/himshe/herthey/themother

Diagnosis, medical conditions and/or allergies *

please specify *

Referrer Information

Name of individual completing the form *

Relationship to client (e.g. self, parent, support coordinator etc.) *

Contact phone number *

Email address *

Booking Preferences

Upon receipt of the completed referral form, unless we need to discuss any of your responses with you first, our Intake Team will develop a Service Agreement for you based on the answers you provide. These are typically blocks of 24hrs, however, assessments alone may be less hours. The agreeement will be sent for your approval, and once approved you will be ready to be offered a suitable vacanciy when it arises.

Please provide the below information to assist us in creating your agreement.

Will you be using NDIS funding or Fee for Service (out of pocket)? *

NDISFee for service

NDIS number *

NDIS plan dates (start date and end date) *

Please upload your NDIS plan here

Browse

My Improved Daily Living (CB Daily Activities) budget is: *

Self-ManagedPlan-ManagedAgency-Managed

Plan Nominee (responsible person for making decisions about NDIS services on the behalf of the individual)

Plan Manager name: *

Plan Manager email address *

Is this a PACE plan?

YesNoUnsure

Preferred Session (you may select multiple) *

Does the client/care team require an interpreter? *

YesNo

If yes, which language?

Background Information

How does your child communicate?

If the individual uses AAC please detail which system they use:

Does the client display behaviours of concern? (Please note: this is to allow us to best allocate and support the individual within Occupational Therapy) *

NoYes

Does the individual have a current Positive Behaviour Support Plan? *

NoYes

Please provide a copy of the plan

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please specify other: *

Do any of the following apply to the client?

Under Guardianship of the MinisterFoster family/alternative care arrangementCourt orderVoluntary out of home care / supported independent living2:1 support requirement

Aquatic Therapy Support

What is your child’s previous experience with water? *

Aquatic TherapySwimming LessonsCasual SwimmingNo Experience

What is your child’s current continence level? (tick all that apply) *

Full IndependenceBladder IncontinenceBowel Incontinence

How does your child cope currently in noisy environments? *

Doesn’t appear botheredWill appear uncomfortable or upsetWill use behaviours to show frustration/dysregulationWill abscond (leave a designated area)Other

Comments *

Does your child have a fear of water? *

YesNo

Comments *

Does your child have any specific interests that they enjoy? *

YesNo

Comments *

What goal areas would your child like support with?

Further Comments

Fine Motor

Object manipulationFinger isolationHand dominanceHand/finger strength

Further Comments

Sensory/Emotional Regulation

Further Comments

Community Participation

Using public restroomsFollowing a visual schedule/ routineLearning community procedures, rules and expectationsAccessing and engaging with the community Transitioning in and out of pool environment

Further Comments

Any other important information you would like to provide?

Thank you for completing this referral form to support in the allocation of Aquatic Therapy Services. A member of our intake team will be in contact with you to discuss next steps.