Intake Form Intake Form Your Details * First Name Last Name Please select * Parent / Carer Client Referrer Phone * Email * Client / Child's Details * First Name Last Name Date of Birth DD/MM/YYYY * Gender * Female Male Other Phone Number (if different to above) Email (if different to above) Notes * Briefly describe diagnosis, main concerns and strengths/interests. Services Required * Occupational Therapy Speech Pathology Counselling (Gympie) Play Therapy- Interplay/Trauma Dietitian Feeding Therapy (Gympie only) Functional Capacity Assessment Clinic Location * Gympie: 84 River Road Maroochydore: Kontiki 55 Plaza Parade Funding * NDIS (self or plan managed) GP Referral Self Funded NDIS Number NDIS Plan Manager's Details How did you hear about Lotus Therapy? Thank you for taking the time to complete the form. Our team will be contact soon to organise sessions.