Complete this form to be placed on our waitlist. Contact us if you would like further information about wait times and available services.

Contact Information

First and Last Name of the Person completing the form

Relationship to person being referred, e.g., parent, self, support coordinator.

Client's First and Last Name

Date of Birth

Day

Month

Year

Gender

Female

Male

Other

First and Last Name of the Person to contact regarding appointments, if different to above.

Phone

Email

If you have responded above with anything other than Cairns, please specify the town below, as well as the school, daycare or nursing home attended, if applicable.

Concerns:

Do you have a child who would benefit from Early Childhood Practitioner (ECP) support? They must be under 9 if on NDIS to access ECP supports.

No, the person I'm referring is not under 9

No, we already have an ECP

No, I have no concerns about any of the below areas

Yes, for playing and interacting with peers and making and keeping friends

Yes, to help prepare for school

Yes to come to daycare and help within that environment.

Yes, for support with early development, including language, literacy, numeracy and/or motor skills.

Yes, I'm happy to see an ECP while I wait for speech or OT.

Yes, for something else:

Additional Information

Do you have a current NDIS plan?

Do you have a current Support At Home package? (for Aged Care)

Is English the main language spoken at home?

Apart from English, what languages are spoken at home?

Is there anything else you'd like to tell us?

Appointments

As we have an extensive waitlist, we like to offer one-off appointments to those who may be interested, when possible. Please indicate when you would like to be contacted.

I only require an assessment - no ongoing therapy

I only want to be contacted when there is a place available for regular therapy

I would like to be contacted at short-notice for a one-off appointment

CONTACT US

Contact Information

Concerns:

Additional Information

Appointments