Ruth Croser Appointment Request

Please fill out and submit the following information and we will contact you for an appointment.

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* Child's first name

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* Child's last name

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* Child's gender

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* Child's date of birth

Date

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* Please fill in contact details

Address

Address 2

Suburb

State

ZIP/Postal Code

Email Address

Home Phone Number

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* Mobile contact for key caregiver

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* Parent / key caregivers' name(s)

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* School / Childcare name and year level or group name

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* Emergency contact and relationship to child

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* Caregiver medicare number

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* Child's number on medicare card

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* Private Health Insurer

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* Private Health number

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* Referred by

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* How do you prefer to be contacted?

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* In a few words, what are your main concerns?

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* Does your child have a diagnosis? If so, please describe...

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* Are you accessing any other support services? Please indicate key people at these support services and/or at school/childcare whom it would be useful for me to communicate with.

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* Please rate your child’s functioning as good, average or challenging in the following areas :

Sleep

Mealtimes

Toileting

School/childcare

General health

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* Any other relevant information?

Fees are payable at the end of a session. Initial consultations or home/school visits are $200, subsequent sessions are $160 per hour.

If, for some reason you are required to postpone or cancel an appointment, please give me at least 24 hours’ notice, otherwise a fee of $50 will be charged to your account.