Participant Intake Form/Service Agreement

Welcome to Our Comprehensive Care Client Intake Form

Thank you for choosing us for your healthcare needs. This form is designed to streamline the process for your enquiries, initial appointments, assessments, and therapy sessions.

What to Expect

General Enquiry: If you’re unsure about your needs, any details or would like to speak to someone directly, please complete the contact details below and press Submit. One of our team members will contact you to assist.

Ready to book: If you are ready to book in for services, please complete the form, sign and submit. If you are not authorised to sign, still complete the form and then enter the contact details of the signaytory and the form will be sent to them to review and sign. Alternatively, signng can be compelted inclinic prior to the first appointment commencing.

What do I need to help complete the form?

NDIS clients - your plan details so you can nominate your service needs. You can optionally upload your Plan to assist our practitioners to prepare in advance or you can bring your Plan to your first session. BSP and Home visit clients need to complete a Risk Assessment.

Medicare Clients - your Medicare Card details, your Enhanced Primary Care (EPC) Plan, you can optionally upload a copy of your EPC within the form.

My Aged Care Clients - details of your plan provider

DVA Clients - your DVA card and referral details

Insurance Clients (Workcover, CTP etc) - Insurer and claim details

Private Paying Clients - proceed to book online for an immediate service booking (excluding Speech and Occupational Therapy and Behaviour Support) or complete the form and the Team will reach out to you.

If you have any questions or need assistance, please don’t hesitate to contact us.

We look forward to supporting you on your journey to better health!

Requesting appointment for *

MyselfSomeone else

Client Details

First Name *

Last Name *

Title

Date of Birth *

Phone Number (Mobile) *

Gender *

Email *

Street Address *

Suburb *

State *

Post Code *

Language *

EnglishNon-English SpeakingRequire an Interpreter

Which language do we require an interpreter for?

Referrer Details

Referrer Name *

Phone Number *

Emails Address *

What is your role? *

I am a GP, Doctor or SpecialistI am an NDIS LAC or Support CoordinatorI am an NDIS Plan ManagerI am a Parent, Guardian or Caregiver.

Company Name

Check out our current capacity and waitimes here

Click here for availabilities

I have checked capacity and am ready to book, be waitlisted or make a referral

I am not ready to book yet and would like a phone call to discuss services

Please give us a little more information around your enquiry *

Preferred Location

Home / School / Telehealth

Please select which clinic you would like to attend:

Alternatively where would you like supports to be provided:

Please add School or an alternate location of where services will be provided *

Risk Assessment (Safety & Home Access Information)

Type of Dwelling *

Is the location considered remote? *

YesNo

Is the location easily accessible from the street? *

YesNo

Is the location visible from the street? *

YesNo

Is there mobile phone reception on the property? *

YesNo

Are exits easily accessible? *

YesNo

Is there parking available? *

YesNo

Please provide more details about parking

Does the location have security features such as locked gates and doors that make exiting difficult? *

YesNo

Are there weapons on the premises? *

YesNo

Are Illegal substances kept on the premises? *

YesNo

Is the location under construction/renovation or extensions? *

YesNo

Are there any areas within the home where hoarded items or excessive clutter could impede safe movement or access, including hallways, doorways, and emergency exits? *

YesNo

Does the property have accessible entry points for wheelchair users, including a clear, ramped or level pathway? *

YesNo

Are there any stairs or other obstacles that could hinder access? *

YesNo

Does the Participant have a known history of verbal or physical abuse? *

YesNo

Are there any triggers we should be aware of? *

YesNo

Please provide further information *

Are there any animals on the property? *

YesNo

Have there been any instances of aggression from the animals? *

YesNo

Please provide further details regarding animals *

Any external agencies indicating significant concerns with home/family environment *

YesNo

Is the client aware and happy for us to be coming to the home. *

YesNo

Is there a requirement for a Carer or Support Worker to be present at the time of the appointment? *

Is there any other information that you would like to make the therapist aware of before going out?

Funding Stream - Please select below

NDIS

Please attach a copy of your current NDIS Plan

Browse

A copy of your plan will be provided to the practitioner to enable us to better understand your needs and provide a more tailored service.

NDIS Plan Number *

NDIS Plan Start Date *

NDIS Plan End Date *

Diagnosis *

Is your Plan a PACE Plan *

YesNo

How to Endorse OHS

Please note Endorsement must be completed prior to appointment

Support Coordinator Details

Support Coordinator:

Phone:

Support Coordinator Email:

Disciplines

Occupational Therapy Assessment Physiotherapy

Occupational Therapy

How much funding would you like to allocate to your Occupational Therapy (Minimum 1 hour at NDIS 193.99 rate) *While the form indicates a 1-hour minimum, please be aware that due to the hourly rate of $193.99, a single hour of support may not provide sufficient funding for you to fully benefit from our services. To ensure we can provide you with the highest quality support, we recommend considering allocating an amount that better meets your long term needs.

What category is your funding for Occupational Therapy being drawn from? *

Improved Daily Living (CB Daily ActivitiesDaily Activities (CORE)

How is your Occupational Therapy funding Managed? *

Agency ManagedPlan ManagedSelf Managed

Tick if your Occupational Therapy supports will be split across 2 different categories

How much funding would you like to allocate to your Occupational Therapy 2 (Minimum 1 hour at NDIS 193.99 rate) *While the form indicates a 1-hour minimum, please be aware that due to the hourly rate of $193.99, a single hour of support may not provide sufficient funding for you to fully benefit from our services. To ensure we can provide you with the highest quality support, we recommend considering allocating an amount that better meets your long term needs.

What category is your funding for Occupational Therapy being drawn from 2? *

Improved Daily Living (CB Daily ActivitiesDaily Activities (CORE)

How is your Occupational Therapy funding Managed 2? *

Agency ManagedPlan ManagedSelf Managed

OT Therapy Total

Please note if Plan Management is selected you must complete Plan Manager details.

Occupational Therapy Assessments

Functional Capacity Assessment In Clinic = $2715.86Functional Capacity Assessment External = $2909.85Specialist Disability Accommodation Assessment (SDA) = $4267.78Assistive Technology = $1939.90Supported Independent Living Assessment = $4655.76Manual Handling = $3879.80

What category is your funding for Occupational Assessments being drawn from? *

Improved Daily Living (CB Daily ActivitiesDaily Activities (CORE)

How is your Occupational Therapy Assessments Managed? *

Agency ManagedPlan ManagedSelf Managed

OT Assessment Total

Occupational Therapy Assessment

Manual Handling

Functional Capacity Assessment - Physical Disability only

What category is your funding for Occupational Assessments being drawn from 2? *

Improved Daily Living (CB Daily ActivitiesDaily Activities (CORE)

How is your Occupational Therapy Assessments Managed 2? *

Agency ManagedPlan ManagedSelf Managed

Speech Therapy

How much funding would you like to allocate to your Speech Therapy? (Minimum 1 hour at NDIS 193.99 rate) *While the form indicates a 1-hour minimum, please be aware that due to the hourly rate of $193.99, a single hour of support may not provide sufficient funding for you to fully benefit from our services. To ensure we can provide you with the highest quality support, we recommend considering allocating an amount that better meets your long term needs.

What category is your funding for Speech being drawn from? *

Improved Daily Living (CB Daily Activities)Daily Activities (CORE)

How is your Speech Therapy funding Managed? *

Agency ManagedPlan ManagedSelf Managed

Tick if your Speech Therapy supports will be split across 2 different categories

How much funding would you like to allocate to your Speech Therapy 2? (Minimum 1 hour at NDIS 193.99 rate) *While the form indicates a 1-hour minimum, please be aware that due to the hourly rate of $193.99, a single hour of support may not provide sufficient funding for you to fully benefit from our services. To ensure we can provide you with the highest quality support, we recommend considering allocating an amount that better meets your long term needs.

What category is your funding for Speech being drawn from 2? *

Improved Daily Living (CB Daily Activities)Daily Activities (CORE)

How is your Speech Therapy funding Managed 2? *

Agency ManagedPlan ManagedSelf Managed

Speech Therapy Total

Speech Assessments

Click here to view what is included in our Speech Assessments

Communication Assessment - Gold = $2909.85Communication Assessment - Silver = $2521.87Diagnostic Dyslexia Assessment = $3297.83Swallowing & MTMP Assessment - Gold = $2909.85Swallowing & MTMP Assessment - Silver = $2521.87

What category is your funding for Speech Assessments being drawn from? *

Improved Daily Living (CB Daily ActivitiesDaily Activities (CORE)

How is your Speech Therapy Assessments funding Managed? *

Agency ManagedPlan ManagedSelf Managed

Speech Assessment Total

Physiotherapy

How much funding would you like to allocate to your Physiotherapy? (Minimum 1 hour at NDIS 193.99 rate) *While the form indicates a 1-hour minimum, please be aware that due to the hourly rate of $193.99, a single hour of support may not provide sufficient funding for you to fully benefit from our services. To ensure we can provide you with the highest quality support, we recommend considering allocating an amount that better meets your long term needs.

How much funding would you like to allocate to your Physiotherapy? (Minimum 1 hour at NDIS 224.62 rate) *While the form indicates a 1-hour minimum, please be aware that due to the hourly rate of $224.62, a single hour of support may not provide sufficient funding for you to fully benefit from our services. To ensure we can provide you with the highest quality support, we recommend considering allocating an amount that better meets your long term needs.

What category is your funding for Physiotherapy being drawn from? *

Improved Daily Living (CB Daily Activities)Daily Activities (CORE)

How is your Physiotherapy funding Managed? *

Agency ManagedPlan ManagedSelf Managed

Tick if your Physiotherapy supports will be split across 2 different categories

How much funding would you like to allocate to your Physiotherapy 2? (Minimum 1 hour at NDIS 193.99 rate) *While the form indicates a 1-hour minimum, please be aware that due to the hourly rate of $193.99, a single hour of support may not provide sufficient funding for you to fully benefit from our services. To ensure we can provide you with the highest quality support, we recommend considering allocating an amount that better meets your long term needs.

How much funding would you like to allocate to your Physiotherapy 2? (Minimum 1 hour at NDIS 224.62 rate) *While the form indicates a 1-hour minimum, please be aware that due to the hourly rate of $224.62, a single hour of support may not provide sufficient funding for you to fully benefit from our services. To ensure we can provide you with the highest quality support, we recommend considering allocating an amount that better meets your long term needs.

What category is your funding for Physiotherapy being drawn from 2? *

Improved Daily Living (CB Daily Activities)Daily Activities (CORE)

How is your Physiotherapy funding Managed 2? *

Agency ManagedPlan ManagedSelf Managed

Physio Total

Dietetics

How much funding would you like to allocate to your Dietetics? (Minimum 1 hour at NDIS 193.99 rate) *While the form indicates a 1-hour minimum, please be aware that due to the hourly rate of $193.99, a single hour of support may not provide sufficient funding for you to fully benefit from our services. To ensure we can provide you with the highest quality support, we recommend considering allocating an amount that better meets your long term needs.

What category is your funding for Dietetics being drawn from? *

Improved Daily Living (CB Daily Activities)Daily Activities (CORE)Health & Wellbeing

How is your Dietetics funding Managed? *

Agency ManagedPlan ManagedSelf Managed

Tick if your Dietetics supports will be split across 2 different categories

How much funding would you like to allocate to your Dietetics 2? (Minimum 1 hour at NDIS 193.99 rate) *While the form indicates a 1-hour minimum, please be aware that due to the hourly rate of $193.99, a single hour of support may not provide sufficient funding for you to fully benefit from our services. To ensure we can provide you with the highest quality support, we recommend considering allocating an amount that better meets your long term needs.

What category is your funding for Dietetics being drawn from 2? *

Improved Daily Living (CB Daily Activities)Daily Activities (CORE)Health & Wellbeing

How is your Dietetics funding Managed 2? *

Agency ManagedPlan ManagedSelf Managed

Dietetics Total

Exercise Physiology

How much funding would you like to allocate to your Exercise Physiology? (Minimum 1 hour at NDIS 166.99 rate) *While the form indicates a 1-hour minimum, please be aware that due to the hourly rate of $166.99, a single hour of support may not provide sufficient funding for you to fully benefit from our services. To ensure we can provide you with the highest quality support, we recommend considering allocating an amount that better meets your long term needs.

What category is your funding for Exercise Physiology being drawn from? *

Improved Daily Living (CB Daily Activities)Daily Activities (CORE)Health & Wellbeing

How is your Exercise Physiology Funding Managed? *

Agency ManagedPlan ManagedSelf Managed

Tick if your Exercise Physiology supports will be split across 2 different categories

How much funding would you like to allocate to your Exercise Physiology 2? (Minimum 1 hour at NDIS 166.99 rate) *While the form indicates a 1-hour minimum, please be aware that due to the hourly rate of $166.99, a single hour of support may not provide sufficient funding for you to fully benefit from our services. To ensure we can provide you with the highest quality support, we recommend considering allocating an amount that better meets your long term needs.

What category is your funding for Exercise Physiology being drawn from 2? *

Improved Daily Living (CB Daily Activities)Daily Activities (CORE)Health & Wellbeing

How is your Exercise Physiology Funding Managed 2? *

Agency ManagedPlan ManagedSelf Managed

EP Total

Hydrotherapy

How much funding would you like to allocate to your Hydrotherapy? (Minimum 1 hour at NDIS 166.99 rate) *Please enter the amount you wish to allocate to this service. Note min amount is $166.99 which will give you 1 hour of supports. If the amount you enter is lower then this we can not accept this form and you will be asked to fill out a new form

What category is your funding for Hydrotherapy being drawn from? *

Improved Daily Living (CB Daily Activities)Daily Activities (CORE)Health & Wellbeing

How is your Hydrotherapy Funding Managed? *

Agency ManagedPlan ManagedSelf Managed

Tick if your Hydrotherapy supports will be split across 2 different categories

How much funding would you like to allocate to your Hydrotherapy 2? (Minimum 1 hour at NDIS 166.99 rate) *While the form indicates a 1-hour minimum, please be aware that due to the hourly rate of $166.99, a single hour of support may not provide sufficient funding for you to fully benefit from our services. To ensure we can provide you with the highest quality support, we recommend considering allocating an amount that better meets your long term needs.

What category is your funding for Hydrotherapy being drawn from 2? *

Improved Daily Living (CB Daily Activities)Daily Activities (CORE)Health & Wellbeing

How is your Hydrotherapy Funding Managed 2? *

Agency ManagedPlan ManagedSelf Managed

Hydro Total

Behaviour Supports

How are your Behaviour Supports funded *

Improved RelationshipsImproved Daily Living (Please note that if you have Improved Relationships in your plan you are not able to use Improved Daily Living)

How much funding would you like to allocate to your Behaviour Management Plan? (Minimum 1 hour at NDIS 222.99 rate) *While the form indicates a 1-hour minimum, please be aware that due to the hourly rate of $222.99, a single hour of support may not provide sufficient funding for you to fully benefit from our services. To ensure we can provide you with the highest quality support, we recommend considering allocating an amount that better meets your long term needs.

How much funding would you like to allocate to your Specialist Behavioural Intervention Supports? (Minimum 1 hour at NDIS 222.99 rate) *While the form indicates a 1-hour minimum, please be aware that due to the hourly rate of $222.99, a single hour of support may not provide sufficient funding for you to fully benefit from our services. To ensure we can provide you with the highest quality support, we recommend considering allocating an amount that better meets your long term needs.

How much funding would you like to allocate to your Behaviour Management Plan? (Minimum 1 hour at NDIS 244.22 rate) *While the form indicates a 1-hour minimum, please be aware that due to the hourly rate of $244.22, a single hour of support may not provide sufficient funding for you to fully benefit from our services. To ensure we can provide you with the highest quality support, we recommend considering allocating an amount that better meets your long term needs.

How much funding would you like to allocate to your Specialist Behavioural Intervention Supports? (Minimum 1 hour at NDIS 244.22 rate) *While the form indicates a 1-hour minimum, please be aware that due to the hourly rate of $244.22, a single hour of support may not provide sufficient funding for you to fully benefit from our services. To ensure we can provide you with the highest quality support, we recommend considering allocating an amount that better meets your long term needs.

Behaviour Support PACE *While the form indicates a 1-hour minimum, please be aware that due to the hourly rate of $222.99, a single hour of support may not provide sufficient funding for you to fully benefit from our services. To ensure we can provide you with the highest quality support, we recommend considering allocating an amount that better meets your long term needs.

Behaviour Support PACE *While the form indicates a 1-hour minimum, please be aware that due to the hourly rate of $ 244.22, a single hour of support may not provide sufficient funding for you to fully benefit from our services. To ensure we can provide you with the highest quality support, we recommend considering allocating an amount that better meets your long term needs.

How much funding would you like to allocate to Behaviour Support Improved Daily Living *

How much funding would you like to allocate to Behaviour Support Improved Daily Living TAS *

What Category of funding is your Behaviour supports being drawn from? *

Improved Daily Living (CB Daily Activities)Improved RelationshipsBehaviour Supports (PACE)

How is your Behaviour support funding managed? *

Agency ManagedPlan ManagedSelf Managed

SBIS Total

BMP Total

PACE SBIS Total

BS IDL

A risk assessment will be sent once this form is submited

Early Childhood Intervention Supports

How much funding would you like to allocate to Early Childhood Intervention Supports? (Minimum 1 hour at NDIS 193.99 rate) *While the form indicates a 1-hour minimum, please be aware that due to the hourly rate of $193.99, a single hour of support may not provide sufficient funding for you to fully benefit from our services. To ensure we can provide you with the highest quality support, we recommend considering allocating an amount that better meets your long term needs.

What Category of funding is your Early Childhood Intervention supports being drawn from? *

Improved Daily Living (CB Daily Activities)Improved RelationshipsBehaviour Supports (PACE)

How is your Early Childhood Intervention support funding managed? *

Agency ManagedPlan ManagedSelf Managed

ECI Total

A risk assessment will be sent once this form is submited

Podiatry

How much funding would you like to allocate to your Podiatry? (Minimum 1 hour at NDIS 193.99 rate) *While the form indicates a 1-hour minimum, please be aware that due to the hourly rate of $193.99, a single hour of support may not provide sufficient funding for you to fully benefit from our services. To ensure we can provide you with the highest quality support, we recommend considering allocating an amount that better meets your long term needs.

What category is your funding for Podiatry being drawn from? *

Improved Daily Living (CB Daily Activities)Daily Activities (CORE)

How is your Podiatry funding managed? *

Agency ManagedPlan ManagedSelf Managed

Tick if your Podiatry supports will be split across 2 different categories

How much funding would you like to allocate to your Podiatry 2? (Minimum 1 hour at NDIS 193.99 rate) *While the form indicates a 1-hour minimum, please be aware that due to the hourly rate of $193.99, a single hour of support may not provide sufficient funding for you to fully benefit from our services. To ensure we can provide you with the highest quality support, we recommend considering allocating an amount that better meets your long term needs.

What category is your funding for Podiatry being drawn from 2? *

Improved Daily Living (CB Daily Activities)Daily Activities (CORE)

How is your Podiatry funding managed 2? *

Agency ManagedPlan ManagedSelf Managed

Pod Total

Plan Manager

Who is your plan manager? *To ensure we can process your service agreement efficiently, please make sure all the information provided is accurate. If you do not have all the required information at the moment, you can select “Save and Continue.” A copy of your form will be emailed to you, allowing you to complete it later once you have gathered all the necessary details. Please only submit the form when all information is correct

Contact Number *

Email address for invoicing *To ensure we can process your service agreement efficiently, please make sure all the information provided is accurate. If you do not have all the required information at the moment, you can select “Save and Continue.” A copy of your form will be emailed to you, allowing you to complete it later once you have gathered all the necessary details. Please only submit the form when all information is correct

Plan Manager calculation

Behaviour Support Plan

Is there a Behaviour Support Plan in Place ? *

YesNo

Behaviour Support Plan

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Please upload a copy of the BSP if available.

Medicare

Medicare Number *

Medicare IRN *

Medicare care expiry *

How many sessions have you been given? *

Doctors Name *

Doctors Phone Number *

Doctors Address *

Doctors Provider No *

Please note there is an out of pocket expense as Medicare does not cover the entire cost of your appointment.

Medicare Disiplines *

Occupational Therapy - Please note Medicare does not cover AssessmentsSpeech Therapy - Please note Medicare does not cover AssessmentsPhysiotherapyExercise PhysiologyDieteticsPodiatry

Medicare Dicipline *

PhysiotherapyExercise PhysiologyDietetics

Please note if you require an OT Assessment or Speech Assessment you will have to select your payer as a Private client. This will incur an out of pocket expense.

Are you under the age of 16? *

YesNo

Parent/Guardian First Name *

Parent/Guardian Last Name *

Parent/Guardian Date of Birth *

Parent/Guardian Contact Number *

Please upload a copy of your EPC

Browse

If you haven't uploaded a copy of you EPC you must bring it to your appointment or will endure an out of pocked fee.

Private

If you are seeking immediate support for the following services Physiotherapy, Exercise Physiology, Podiatry and Dietetics , we encourage you to book an appointment directly using the link below. This method ensures you receive the quickest assistance possible. Simply choose your preferred time and date, and we’ll ensure you’re taken care of promptly.

Book Now!

Alternatively, you can choose to submit this form to enter the intake process. Please be aware that opting for the intake process may result in a longer wait time before support is provided.

For Speech Therapy and Occupational Therapy , please finish completing the form.

For your convenience, all payments can be made at our reception desk. Thank you for choosing our services.

Please note that payment is required on the day of your appointment .

Insurance - Work cover or CTP ONLY

Claim Number *

Date of Injury *

Insurance Case Manager *

Phone Number *

Email Address *

Discipline Insurance *

Exercise Physiology Physiotherapy

Approval Letter

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Please attach a copy of your approval letter from your insurer for your treatment.

My Aged Care

My Aged Care Number *

Home Care Package Provider *

Email address for invoicing *

Please select below which service you would like to receive

Occupational Therapy

Speech Therapy

Podiatry

Physiotherapy

Exercise Physiology

Hydrotherapy

Dietetics

Occupational Therapy Assessment - Functional Capacity Assessment

Speech Therapy Assessment - Swallowing Assessment

Please note we are not registered as CHSP Providers

DVA

What is your DVA Number *

Which DVA Card do you hold *

White CardGold Card

Please attach Referral *

Browse

Communication Consent

Please select if you would like to receive:

SMS - Reminders

SMS - Marketing

Email - Reminders

Email - Marketing

How did you hear about us?

Google

Recommendation

Other

Expo

Existing Client

I received an email

Total Service Agreement Amount

Total Amount

Terms and Conditions

I have read and agree to the terms and conditions
*

I have read and consent to the Pre-Paid Policy *

I have read and consent to the Cancellation Policy *

Any additional information you wish to provide to your allocated Practitioner?

Any Additional Documentation

Browse

EG - Behaviour support plan, Occupational therapy or Speech Therapy reports, Medical summary etc....

If this is for Quote purposes only please select save and continue under the submit button below and a copy will be sent to you.

Participant/Participant's Representative

I have a Public Guardian in place

The Public Guardian is a public official appointed by the Guardianship Division to make healthcare, lifestyle and medical decisions for a person who lacks decision-making ability.

Public Guardian Email address

Authorisation and Document Signing

I am authorized to sign on behalf of myself/the participant (you may be required to provide evidence of authorisation)

I do not have permission to sign on behalf of the participant

I would like to sign in clinic

If you do not have permission to sign on behalf of the participant:

Populate the signatories email address below.

Please select 'Save and continue' below (it's right at the bottom of the form in orange and can be hard to see!) .

A window will pop up and prompt you to enter the email for the authorised signatore.
Enter email of signatore and press send.
Please note there will be no submit button until the form is signed.
Signatory will receive a link via email to the completed form for them to sign.
Signatory will sign and submit, completing the form process.

Email address of Authorised Signatory *If the authorised signatory does not have an email address, enter an alternative email address and make arrangements with the participant to sign. i.e support coordinator, guardian, referrer.

Name of the person signing *

Signature *

Draw signature|Type signatureClear

Please note that without a signature we can not schedule an appointment and the form will be returned for signature to the correct party for signing.

Date *

Name of Person Signing Form

Signature

Draw signature|Type signatureClear

Please note that without a signature we can not schedule an appointment and the form will be returned for signature to the correct party for signing.

Date

Blacktown, Campbelltown, Cessnock, Croydon Park , Sylvania, Hornsby, Nowra - ABN - 76 128 542 236

Liverpool - ABN - 57 637 316 511

Batemans Bay - ABN - 77 643 773 111

Goulburn - ABN - 58 615 423 446

Dodges Ferry, Moonah, Mornington, Brisbane - ABN - 27 606 845 498

North Rocks - ABN - 30 678 552 782

Save and Complete Later