Home How to get support Enquire about supportsEnquire about supportsStep 1 of 50%Thank you for choosing us! We need a bit of information before we can get started.This form will take about 5 - 10 minutes to complete. We will contact you after you have completed this form to discuss services.I am completing this for: * RequiredMyselfSomeone else (child / someone I care for / I am referring someone else)Where did you hear about Kern?GoogleKern StaffNDISSocial MediaSupport Coordinator Capacity NewsletterTraditional Marketing (brochure, newspaper)WebsiteWord of MouthOtherOtherDetails about the person making the enquiryFirst name * RequiredLast name * RequiredMobile * RequiredEmail address * Required Relationship to participant * RequiredParentCarerGuardianSpouseHealth ProfessionalSupport CoordinatorLocal Area CoordinatorOtherOtherDetails about the participantFirst name * RequiredLast name * RequiredPreferred GenderAge * RequiredSuburb and post code * RequiredMobile * RequiredEmail address Diagnosis or condition (if relevant)Secondary diagnosis or current health concernsContact details * RequiredSame as the referrerOtherMobile * RequiredEmail address Who would you like us to contact? * RequiredEnquirerParticipantSome more helpful information for us to knowDoes the participant or enquirer need an interpreter?YesNoCountry of birth?Main language spoken at home?Does the participant identify as Aboriginal and/or Torres Strait Islander?YesNoAre you funded by the NDIS?YesNoIf no, how will your supports be funded?What is your NDIS number?What are your NDIS plan dates?What are your NDIS plan goals?Please share a copy of your NDIS plan to better help us support you.Accepted file types: pdf, doc, docx.What supports are required?Please carefully select the supports that you require or that are documented in the NDIS plan. If you are unsure, please select ‘other’ and we will contact you to discuss further.Occupational Therapy Assistive technology/equipment - Basic (e.g. shower chair, tipping kettle, non-slip mat, modified cutlery) Assistive technology/equipment - Complex (e.g. wheelchair, lift recliner chair, electric adjustable bed) Community access & participation (e.g. public transport, social groups) Domestic chores Sensory and emotional regulation Functional Capacity Assessment (FCA) Home modifications - Basic (e.g. small modifications to the home such as installation of grab rails, bidet or removal of a shower hob) Home modifications - Complex (e.g. large modifications to the home such as removing bath basin, widening door ways, creating new rooms) Job skills/readiness Self-care routines (e.g. dressing, toileting, mealtimes, sleep) Sexuality and relationships Specialist Disability Accommodation (SDA) Supported Independent Living (SIL) OtherOtherPhysiotherapy Assistive technology / equipment (e.g. walking aids, manual handling aids such as hoists, slings, transfer aids, standing frames, trikes, alternative positioning, beds) Balance and coordination Developmental milestones Exercise programs Falls prevention Functional Capacity Assessment (FCA) Functional Independance Gait retraining Hydrotherapy Injury Prevention Manual handling Movement awareness and control Night time positioning Pain Management Seating - wheelchair and seating assessment and prescription - Basic or Complex Sensory and motor coordination OtherOtherExercise Physiology Community access and participation Exercise programs General health and wellbeing Hydrotherapy OtherOtherSpeech Pathology Articulation, speech clarity and fluency Augmentative and Alternative Communication (AAC) including low and high tech options Comprehension and following instructions Language development Mealtime management (e.g. chewing, feeding, swallowing) Social and play skills Stuttering OtherOtherPsychology Coping skills Emotional awareness Mental health support – anxiety, depression, trauma/PTSD, grief/loss, suicidal ideation/self-harm, chronic pain Parental support around child displaying behaviours of concern Refusal Social skills Stress management OtherOtherPositive Behaviour Support *Must have NDIS Capacity Building Relationships Funding Behaviour Support Plan Behaviour Assessment Screen Functional Behaviour Assessment Family systems therapy Safeguarding and managing risk Support to improve participant quality of life and well-being Support to manage/reduce behaviours of concern Support to reduce use of restrictive practices OtherAdditional informationCan you describe the support you are seeking or your needs? * RequiredPreferred location you wish to receive supports (Suburb or school name)? * RequiredAs a mobile therapy provider, Kern provides supports where you need it most, in the home, school or community setting across the southern Perth, Bertram and Mandurah region. We also offer clinic-based support within our Bertram and Mandurah clinic.Are there any days and / or times that you are unavailable for therapy?Are there any challenges that the participant, family or friends are experiencing that we should know about? (e.g. separation, grief, housing, financial concerns)Is there anything else that you would like us to know so that we can better support you?
