CAF002.01

Clear drawing

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:

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 provider diagnosis.

Comments:

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

Name of School or Day CarePlease provide school / day care name if you have selected this as an option for visits.

Location of Therapy *

ClevelandMinyamaVarsity Lakes

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

Self Managed - Payment is require on the day of appointment. This can be made in person at reception, via phone, or processed via our Medipass System. Further details will be discussed when contacted to schedule intial appointment

NDIA - Participants NDIS Number to be provided for Optimum Movement to request payment.

Plan Managed - Participants plan Manager details are to be provide. (Email address for invoices and Coordinator and best contact Number to be provided.)

Costs: Further details will be discussed at time of call.

Initial appointment is scheduled for 2 x 1hour sessions - $193.99 per/hour (Total cost for initial $387.98)
Initial appointment scheduled with senior OT for 2 x 1hour sessions - $200 per/hour (Total cost for intial $400.00)
Regular Cost for 1 hour therapy session - $193.99
Regular Cost for 1 hour therapy with Senior OT - $200.00
Mobile Costs - dependent on location. $16.16per 5 minutes

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:

Signature *

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Date *

Signatures Name: *

Referral Details

Referred Name: *

Referrers Contact No:

Email Address:

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

YesNo