Everyday Learning & Therapy Registration & Booking Form V2

Everyday Learning & Therapy Registration & Intake Booking Ringwood

Enter your child's details below to register for service from our Ringwood based team, and to book your online Intake Appointment. If you are wanting to register more than one child, please complete a separate form for each child.
To make sure we are providing you with what you need, please let us know:*

We are ready to start service now and have everything in place for that to happen, including a current NDIS plan that I can access or access to private or other funds to cover costsI would like to know more about your service before committing to an Intake Appointment
One of our Customer Care Team will give you a call to talk more about Noah's Ark and what we can offer, to support your decision making about service for you and your child.
Child's Name*

First NameLast Name
Child's Date of Birth*

DayMonthYear
Child's Gender*

MaleFemaleOther
Child's home address*

Street Address

Street Address Line 2

CityState

Post Code
We deliver our Everyday Learning & Therapy services where you need them - at home, at your child's education setting or other relavant locations in the community.

The Ringwood team travels up to 30 minutes from the office, if we need to travel further than this to deliver your service we will discuss options with you.
We will be accessing the following funding to cover payment for these services:*

NDIS Funding - my child has a current NDIS plan that I can access for our Intake AppointmentDET-CoS (Department of Education - Continuity of Support) FundingPrivate Funds
You have indicated that you will be paying privately for our services, please be aware that our Fees are in line with current NDIS Pricing Arrangments & Price Limits.

Our current hourly rate is $193.99 for all client services, including private paying clients.
Parent/Carer Name*

First NameLast Name
Parent/Carer Email*
example@example.com
Parent/Carer Phone Number*
Please enter a valid phone number.
I confirm that my child has a current NDIS plan to access funds for this service.

YesNo
I confirm that I have a copy of my child's NDIS plan that I can access during my intake appointment.

YesNo
Please call our Customer Care team on 1800 819 140 to discuss options.
I would like to access (if you are unable to choose a discipline, this indicates that we do not have availability with that therapist at this time) *
When possible, I am also interested in accessing:

a Speech Pathologistan Occupational Therapista Specialist Educatora Physiotherapista Psychologist
Our Intake appointments take place via telehealth (video), once you have booked your preferred appointment time we will send you a return email containing a Google Meets link for our meeting. If connecting via video does not suit your needs, please let us know and we can plan an alternative.
I understand that our Intake Appointment will take place online and that I do not need my child with me at this time.*

Yes
Will you require an interpreter to complete our Intake Appointment?*

YesNo
What language interpreter do we need to organise for our appointment? *
Available Appointments - select your preferred option *
What would you like to see as an outcome from receiving Everyday Learning & Therapy Services from Noah's Ark? *
Is there anything else you would like to share with us:
How did you hear about the availability of this service?

Noah's Ark WebsiteFaceBookInstagramSource Kids ExpoWord of MouthFrom Another ServiceOther
Date

DayMonthYear
EL&T Register & Book Intake V2 July 2024
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Everyday Learning & Therapy Registration & Intake Booking Ringwood