Queensland Rehabilitation Specialists
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Occupational Therapy intake form
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Patient Name
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First
Last
Patient Date of Birth
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Are you currently covered under NDIS?
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NDIS Plan Managed
NDIS Self Managed
Private Health
EPC (Enhanced Primary Care Plan)
DVA
NDIS Number:
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Occupational Therapy Goals
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Upper Limb Occupational Therapy Goals
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Plan Management Company (n/a if not applicable)
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NDIS Package Start Date
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Current NDIS Goals
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Other therapies currently involved:
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Physiotherapy
Exercise Physiology
Speech Pathology
Psychology
Dietetics
Other
Referral/ more information:
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Max file size: 20MB
Intensive Block Information:
To assist with the development of neural pathways, enhancing motor control and restoring sensorimotor function QRS
have implemented intensive blocks. Through repetition and practice of task specific activities including the use of the SaeboFlex we have been able to engage meaningful long term results for patients.
It is recommended to use the SaeboFlex daily for 45 minutes per day to create neuroplastic change.
*Please note the intense blocks can be quite fatiguing. Other therapies may need to cease during the period.
Have you discussed your plan with Jean?
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No, I need to book a telehealth appointment
Yes, we have a tentative plan
Intensive Block Options
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1 week intensive (5 appointments)
2 week intensive (10 appointments)
6 week intensive (2-3 appointments per week)
10 week intensive ( 1 appointment per week - 10 weeks)
Not interested in intensive blocks
Joint Botulinum Assessments only
Would you be interested in participating in group Occupational Therapy sessions?
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Yes
No
I would like some more information
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Home
Providers
For Patients
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Patient Information
Botulinum Toxin
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Referral Form