General Information

Patient first name

Patient surname

Date of birth

Email Address

Home phone

Mobile phone

Home address

How did you find out about us?

Do you identify as Aboriginal or Torres Strait Islander?

Yes No

Do you require an interpreter?

Yes No

Child Care’s / Kindergarten / School name:

Emergency Contact Information

Emergency contact

Phone

Emergency contact’s relationship to you

Funding & Fees

How will you fund the sessions? *

NDIS number (if applicable)

Plan Manager email (if applicable)

Medicare number and reference number

You agree for payment to be provided after service delivery has been confirmed.

On the occasion that therapy service is provided without a parent/carer present, you will receive a summary of the session. In this case, you give consent for the relevant person in the location to sign and confirm service delivery.

The price for therapeutic supports is $193.99 per hour. This rate is subject to change.

Cancellations

Function Focus Allied Health will apply the cancellation fee of $193.99 to all cancellations.

A cancellation is a short notice cancellation if the client:

• Does not show up for a scheduled support within a reasonable time, or is not present at the agreed place and within a reasonable time when the provider is travelling to deliver the support; or

• Has given less than two (2) clear day’s notice.

Travel

Travel charges applies to all consultations based on time taken to travel to the client’s setting for therapy at the rate of $193.99 per hour and any additional cost related to Provider Non-Labour Cost (such as tolls, parking or running cost).

Health Information

What are you seeing us about? What are your main concerns and challenges? *

Have you seen a medical doctor in the past for these conditions?

YesNo

Doctor

Date

Treatment

Please list any medications you are currently taking

Medications

Dose

Please list any allergies

Allergy

Severity

Upload medical history or reports

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Additional medical history

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Consent

I confirm that above information I have provided is true, complete and accurate. *

I understand the information shared may include personal details, therapy detail, goals & outcomes, assessments, recommendations or specific information relating to equipment. I understand that information is not given to any other third party for any reason (other than by law) and this information is protected in Victoria by the Commonwealth Privacy Act and the Victorian Health Records Act. I understand that the information gathered will be stored securely for a minimum of five years. I provide my permission to collect and disclose personal and health information to all the relevant professionals involved in the care of the person listed in this agreement. Should there be any information that would not wish to be disclosed, please provide further details below: *

Signature

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Date