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Client details
Clients name
*
First name
Last name
Gender
*
Female
Male
Other
Date of Birth
*
Diagnosis (if applicable)
Ethnicity
*
African
American
Asian
Chinese
English
Filipino
Indian
Japanese
Korean
Maori
Maori and Pakeha
Middle Eastern
NZ European
Pacific Island
Romanian
Samoan
South African
Tongan
Parent/caregiver details
Parent/Caregivers Name
Postal Address
Parent/caregiver phone number
*
Parent/caregiver email
*
School Information
School
School Address
School contact name and contact details
Other professionals
Speech Language Therapist Name, Service History, Contact details
Physiotherapist Name, Service History, Contact detai
Occupational therapist Name, Service History, Contact detai
Paediatrician Name, Service History, Contact detai
Other specialists, Name, Service History, Contact details
Permission to contact other professionals
No
Yes
Medication
No
Yes
Medication details
Carer support funding
No
Yes
Are you an ACC ISSC Sensitive Claims client?
Tick if 'yes', leave blank if 'no'
Are you seeking ACC ISSC Sensitive Claims cover?
Tick if 'yes', leave blank if 'no'
Other information
Reason for referral
Hoped for outcome
Conditions that therapist needs to be aware of
(epilepsy, challenging behaviour, etc)
Relevant strengths or difficulties
Means of communication
(speech, Makaton, etc)
Languages used at home
Sibling's Names & DOB
Previous Dance or Arts Therapy?
No
Yes
Where did you hear about DTNZ?
Group
Inquiries
Please check the highlighted fields
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