CAF002.02

Client Intake Form

Participants details

Family Name: *

Given name/s: *

Preferred name:

Date of Birth: *

Gender

Male FemaleNot stated

Participants Contact details

Address:

Mobile Number: *

Postal Address:Complete if address is different from the above.

Work Phone:

Email Address: *

Preferred Contact method:

MobileWork phoneEmailAny of the above

Main Contact:

Main Contact: *

ParentGuardianSupport CoCarer

Name: *

Relationship: *

Carer/Family Details :

Name: *Please provide First and Last name.

Email Address

Mobile Number:

Other Contact Number:

Please list goals and concerns: *

Does the Participant have a diagnosis: *If you have answered yes. Please provide diagnosis.

Are there any behaviours of concern or medical needs that the therapist should be aware of? *If you have selected 'other', please add these in the comment section below.

Comments:

If answered yes to any of the above, Does your child have an existing Positive Behaviour Support Plan?

Comment

Preferred TimesPlease add time preference in the comment section below. We do our best to schedule your preferred times where we can, however this is not always guaranteed.

Would you like to take last minute cancellations?

YesNo

CommentPlease provide details of preferred time if you did not select anytime in the comments below. Please note as this may be your preference we cannot guarantee this will be available at the time of booking, but try to accommodate where possible.

Funding Availability:

NDISMEDICAREPRIVATE HEALTHNONE

If select NDIS Please provider details:

Self ManagedNDIA Plan Managed

Plan Manager details:

NDIS Number

Admin Only:

Please note that costs do not need to be discussed if you are adding a client to the waiting list rather than booking directly into the diary. This discussion will take place when we contact them to schedule their initial appointment.

However, if a parent or guardian requests cost details or you are booking into the diary from the intake call, provide the following details:

- 3-Hour Initial Assessment Package: $582.00

- This includes two 1-hour client appointments and one hour of total non-face-to-face time.

- Non-face-to-face time covers clinical notes, preparation, document review, and assessment scoring.

- Reports: $193.99 per hour (additional cost)

Standard Consultation - 70 minute standard consultation 55 minutes direct therapy - Clinic / Telehealth /community visit 15 minutes non face-to-face clinical time Amount $226.97 Senior amount $234.00
Short consultation - 60 minute short consultation 45 minutes direct therapy - Clinic / Telehealth / community visit 15 minutes non face-to-face clinical time Amount $193.99 Senior amount $200.00
Mobile Costs - travel costs apply when booking community, home, school or daycare visits. These costs will be discussed and quoted during the appointment scheduling process. Bookings will be finalised once the travel fees have been confirmed.

Specific requirements/preferences:

ClinicMobile appointment

Interests, physical / cultural / belief-based requirements. Travel cost to be discussed at the time of scheduling mobile appointment if required.

If modifications to existing facilities or processes may be required, describe here:

Referral Details

Referred Name: *

Referrers Contact No:

Email Address:

Do you consent to Marketing information? E.g. Upcoming Group programs or appointments. *

YesNo

Date intake form completed *

Intake form completed by: *