Western Kids Health Appointment Enquiry Form

If you are interested in booking a face to face or telehealth appointment, please fill out this form and our administration team will contact you. Please note: Peak period appointment requests (e.g. early mornings and late afternoons) may be subject to a waitlist. We encourage families to consider flexibility and consistency when booking appointments to support the best possible outcomes.

Legal First Name *

Last Name *

Child's Preferred Name

Child's Date of Birth *

Childs Age *

Child's Sex Assigned at Birth *

MaleFemaleRather not say

Preferred Pronouns (if applicable):

Caregivers Name (if under 18 years old) *

Email Address *

Contact Number *

What was the name of the doctor, nurse or health professional who referred you?

Have you attended Western Kids Health in the last 12 months? *

YesNo

Is your child is part of a separated family? *

Yes - to ensure your enquiry is processed please confirm below that you have read our policy belowNo

I agree to Western Kids Health's Separated Family
As your child is part of a separated family, we kindly ask that you agree to our Separated Parent Policy prior to your appointment. Where applicable, please ensure the other parent/guardian is aware of your plans to engage Western Kids Health in your child’s care. https://westernkidshealth.com/separated-caregiver-policy/ *

Are there any court orders, family court matters, or government agencies involved in your child’s care? If yes, please note that a copy of the relevant court order will need to be provided to Western Kids Health prior to commencing services. *

YesNot Applicable

NDIS Funded Participants

If your child is a self-managed NDIS particpant please fill out all fields below.
Your enquiry will not be triaged if it is incomplete.

Please reply with your top 'checkbox' descriptions that allow us to screen for suitability of scope *

My child requires equipment to be mobile (eg wheelchair, walking frame)My child requires a prosthesis to be mobileMy child has difficulty following instructionsMy child wears hearing aids or has hearing lossMy child is visually impaired (low vision or blindness) My child has difficulty coping in new or busy environments My child uses a communication deviceMy child is non verbalNone of the above

My child is a self managed NDIS participant and I have read, fully understood and agree to the T&Cs of services at Western Kids Health https://westernkidshealth.com/ndis-sa-tcs/ *

My childs' NDIS Provider Number *

My Childs' Plan Start Date *

My Child's Plan End Date *

Copy of current NDIS Plan Goals (including valid plan dates) *

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Third Party Insurance Funded

This includes ICWA, MVA and other insurance funding. Please complete all fields, otherwise this enqiry will not be triaged.

Case Manager Name *

Case Manager Phone *

Case Manager Email *

Case/Reference Number *

Other Funding

Contact Name *

Contact Phone *

Contact Email *

I understand this enquiry is for private services only. If I wish to use third party funding, I will complete the separate registration here: https://westernkidshealth.com/services/ndis-services/ *

Yes

Which clinic(s) location do you prefer to attend? Please note our mental health, complex care, gender diversity and part of the feeding clinic are only at Victoria House, Shenton Park.

Victoria House - Shenton ParkHillarysEither LocationTelehealth

Diagnosis (if known)

Main concern or reason for referral to Western Kids Health? Please provide detailed information to assist with triage process *

This is a high‑demand service. Current wait times are approximately 12 weeks. Our friendly admin team will contact you when an appointment becomes available. On submission of your enquiry the clinic will triage and applied to the wailist.

What Mental Health Services were you hoping to access? *

PsychologyOccupational Therapy (Mental Health)

What Complex Care Services are you hoping to access? *

PhysiotherapyPsychologyOccupational TherapyDietetics

What Gender Diversity Services were you hoping to access *

PhysiotherapyPsychologyOccupational Therapy (Mental Health)Dietetics

What Continence Services are you hoping to access? *

PhysiotherapyOccupational Therapy

Which feeding therapist, were you hoping to access in our feeding team? *

Occupational TherapySpeech PathologyDieteticsAny of the above feeding therapists

What Orthopaedic & Sports Service are you hoping to access *

PhysiotherapyPsychologyDietetics

What Early Intervention services were you hoping to access *

PhysiotherapyOccupational TherapySpeech PathologyDietetics

What would you like to achieve with therapy?

If your child has any of the following symptoms, it is important that they are screened by a GP prior to your first appointment:

Blood in their urineo Urinate less than three times a day
You suspect they might have a urinary tract infection (UTI)
Their stool (poo) is black, dark red or has blood or mucous in it.
They have not opened their bowels for more than seven days

My child either does not have these symtopms above, or if they do, we have been assessed by our GP *

The client identifies as *

TransGender DiverseGender Questioning Unsure

In your own words, what is the main concern you want help with? (1–3 sentences)

Mobility most days: *

IndependentNeeds some supportUses an aid (e.g., crutches/walker/wheelchair)Mostly bedbound / very limited

Self-care (e.g., showering, dressing, eating, toileting) compared to what’s typical for their age: *

Age-appropriate / mostly independentNeeds some helpNeeds a lot of help

Overall impact on daily life right now (0: minimal/none through to 10: severe impact) *

Are there any important medical tests, specialist appointments, or investigations still underway to understand your child’s symptoms? *

Is there previous trauma? *

What are the current living arrangements? (e.g., separated, multiple households) *

Are there any risk concerns? Any history with non-suicidal self-injury, suicidal thoughts or behaviours, violence towards others? *If yes, please provide details. *

Is there any further information that is important for us to know at this stage?

By submitting this form, I acknowledge that I have read and understood the following: • Western Kids Health Attendance and Cancellation Policy: https://westernkidshealth.com/cancellation-policy • Western Kids Health Service Guidelines: https://westernkidshealth.com/wp-content/uploads/2025/11/2025-Western-Kids-Health-Terms-of-Service.pdf Western Kids Health clinicians may also use a secure documentation assistant to help draft clinical notes during consultations. This allows clinicians to focus more on children and families during sessions. All notes are reviewed and approved by the clinician before being saved to the clinical record. If you would prefer that this tool is not used during your appointment, please let our team know at any time. I acknowledge that I have read and understood the information above. *

Please upload any relevant referrals or investigations

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Verification *

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