CliniKids Clinical Services Enquiry Form

Today's date*

Enquirer / Parent Information

Please note that CliniKids clinical services are only suitable for children aged 0-8. We do not advise joining our services waitlist if your child is 8.5 or older, as they will likely need to be transitioned to other service provider soon after commencing services.

Your role*

Select

Enquirer / Parent First Name*

Enquirer / Parent Last Name*

Best contact number*

Best email address*

Please note it is important you check this email regularly for waitlist confirmation and service offerings

Address Line 1*

Suburb*

State*

Select

Postcode*

Child's Information

(Please complete separate enquiry form for each child)

Child's First Name*

Child's Last Name*

Child's Gender*

Select

Child's DOB*

Does the child have an ASD diagnosis?*

Select

Does the child have other developmental delays?*

Select

Service Information

Are you currently receiving services?*

Select

Which clinic are you interested in attending for services?

Joondalup

Subiaco

Either

Do you have NDIS funding?*

Select

Which day suits best for appointments?*

Select

Which time of the day suits best for appointments?*

CliniKids is generally open from 8.30am to 4.30pm

Select

If a spot becomes available outside of your preferred day and time, do you want to be contacted?*

Yes - please contact me

No - only contact me if the time matches my availability

How did you hear about CliniKids*

Are you interested in being contacted for research?*

Yes

No

Not sure

Please add any additional notes you would like to share:*

Send me a copy of my responses