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Centre of Movement Intake Form

UEU 4 Scaled

Desired Clinic Location(Required)

Program of Interest (click all that apply):(Required)

Intensive Therapy - Three Weeks

Intensive Therapy - One Week

Regular Therapy

Other

Other

How did you hear about COM(Required)

how did you hear about COM other

Availability

When would you like to attend the Centre of Movement?(Required)

What time/s are best for your child to engage in therapy?(Required)

Will you need a report following this intensive?(Required)

How will your child’s therapy be funded?

Parent/Caregiver Details

First Name(Required)

Last Name(Required)

Address(Required)

Street Address

Street Address Line 2

Street Address Line 2

City / Town / Suburb(Required)

City / Town / Suburb

State / District(Required)

State / District

Post Code(Required)

Post Code

Country(Required)

Country

Contact Information

Phone Number(Required)

Include country and area code

Primary Email Address(Required)

example@example.com

Additional Parent/Caregiver Details

First Name

Last Name

Phone Number

Include country and area code

Email Address

example@example.com

Primary Language

Do you have a need for interpretation services?

Yes

No

Child's Details

First Name(Required)

Last Name(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Date

Gender(Required)

Male

Female

Prefer not to answer

Medical History

Primary Diagnosis

Secondary Diagnosis

Date of Diagnosis

MM slash DD slash YYYY

My child presents with hearing concerns.(Required)

Yes

No

My child presents with vision concerns.(Required)

Yes

No

My child presents with fatigue concerns.(Required)

Yes

No

Medications

Current Weight(Required)

Current Height(Required)

Has your child previously had or currently have a heart condition?(Required)

Yes

No

A close relative who has died suddenly from a heart condition before the age of 50?(Required)

Yes

No

Uncontrolled epilepsy or seizures/convulsions?(Required)

Yes

No

Not Identified

Does your child have a seizure management plan?(Required)

Yes

No

Fainting or dizzy spells with physical activity/exercise?(Required)

Yes

No

Not Identified

Diabetes?(Required)

Yes

No

Not Identified

An asthma attack requiring immediate medical attention at any time over the last 12 months?(Required)

Yes

No

Not Identified

Anaphylactic reactions or allergies?(Required)

Yes

No

Not Identified

Recent surgery or hospitalisations?(Required)

Yes

No

If yes, please provide details

When was the date of your child's last hip/pelvic x-ray?

MM slash DD slash YYYY

Date

Right Hip: Percentage Subluxation

Left Hip: Percentage Subluxation

Has your child now or ever had a diagnosis of decreased bone density?(Required)

Yes

No

If yes, please detail more about your child's low bone density

Has your child now or ever had a diagnosis or concerns of scoliosis?(Required)

Yes

No

If yes, please detail more about your child's scoliosis degree

Has your child ever had a fracture?(Required)

Yes

No

My child currently receives (click all that apply):

Feeding Therapy

Occupational Therapy

Physiotherapy

Exercise Physiology

Speech Therapy

No therapy at this time

Please list any other therapies your child participates in, including any intensive programs.

Developmental Skills/Goals

What do you and your child hope to work towards during therapy?

Gross Motor Skills

	Just getting started	Making progress	With equipment	Independent
Head control
Roll
Reach
Sit
Crawl
Pull to Stand
Stand
Take Steps
Walk
Run/Jump/Hop
Coordination

Gross Motor Skills Comments or Goals

Fine Motor/Activity of Daily Living Skills:

	Exploring	Gaining control	With assistance	Independent
Hold object with both hands
Hold objects functionally
Brings objects to mouth
Uses hands to play
Helps with dressing

Fine Motor/ADL Skills Comments and Goals

Cognition & Learning

	Still developing	Needs support	Almost there	Confident & independant
Attention & focus
Emotional regulation
Behavioral control
Language & communication
Academic learning

If there are specific goals related to cognition and learning, feel free to include them here.

Sensory Processing Comments and Concerns.

Include here any information that may be helpful for us to better support your child's sensory needs. Please detail any goals that pertain to sensory processing.

New Zealand Only

The following questions only need to be answered by our NZ clients

Would you like speech therapy to be included in your intensive?

Yes

No

Is there any other information that you would like us to know?

We're Excited to Have You On Board

At the Centre of Movement, our mission is to revolutionise children’s lives by unlocking their potential through the power of movement.

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Services

Intensive Therapy Program
Trexo Robotics
Occupational Therapy
Physiotherapy
Exercise Physiology

Intensive Therapy Program
Trexo Robotics
Occupational Therapy
Physiotherapy
Exercise Physiology

Cuevas Medek Exercise
Gait Training
Hydrotherapy
The Tomatis Method®
TheraSuit Method®

Cuevas Medek Exercise
Gait Training
Hydrotherapy
The Tomatis Method®
TheraSuit Method®

Contact Us

Centre of Movement, 4/20 Kortum Drive, Burleigh Heads, QLD 4220
info@centreofmovement.com.au
(07) 56369458
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