Allied Health Home Therapy Program

Providers Details

Providers Name

Discipline

Occupational Therapy

Speech Language Pathology

Psychology

Physiotherapy

Nutrition/Dietetics

Company of Employment

Interventon History with the Client

Assessment Only

Ongoing Intervention < 3 Months

Ongoing Intervention 3-6 Months

Ongoing Intervention 6-12 Months

Ongoing Intervention 12+ Months

No Intervention

Preferred Contact Details

Client Details

Please include details of this clients functional challenges relevant to therapy assistant support being provided.

Client Name

Client Date of Birth

Parents Name and Contact Details

Summary of Clients Diagnosis and Medical History (please include details of any medical alerts, allergies or adverse social conditions that may be relevant)

Behaviours of Concern (if any)

Hitting/Scratching

Biting

Shouting

Task Avoidance

Absconding

Seld-Harm/Self-Injurous Behaviour

Anxious Outbursts

Other

Please describe more about the issues noted above (note triggers, PBS plan, etc)

Areas of Difficulty (Identified in your most recent assessment)

Priority 1 Goal

Priority 2 Goal

Priority 3 Goal

Therapy Home Program to Complete

Please include details of therapy activities that you would like the therapy assistant to complete with this client during home-based intervention sessions. Please include grading options and frequency/duration required. If you have additional information to provide (e.g. worksheets, exercise visual guides) please email these to sam@collaborativepartnerships.com.au and note this child's name and DOB in the subject line).

Activities To Complete:

Additional Notes:

Recommended Frequency

1x Per Week

2x Per Week

3x Per Week

4x Per Week

Recommended Location

Home

Clinic

School

Kindergarten/Daycare