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:
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
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:
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.Format: 0000 000 000.
I confirm that my child has a current NDIS plan to access funds for this service.
I confirm that I have a copy of my child's NDIS plan that I can access during my intake appointment.
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:
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.
Will you require an interpreter to complete our Intake Appointment?
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?

Other
Date

DayMonthYear
EL&T Register & Book Intake V2 July 2024
Should be Empty:

Everyday Learning & Therapy Registration & Intake Booking Ringwood