My Aged Care Intake Form

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 do I need to help complete the form?

My Aged Care Clients - Details of your plan provider

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 *

Check out our current capacity and waitimes here

Click here for availabilities

Preferred Location

Home / School / Telehealth

Please select which clinic you would like to attend:

Alternatively where would you like supports to be provided:

Please address of 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 there mobile phone reception on the property? *

YesNo

Are exits easily accessible? *

YesNo

Is the location visible from the street? *

YesNo

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

YesNo

Is there parking available? *

YesNo

Please provide more details about parking

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, and 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?

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

Communication Consent

How did you hear about us?

Existing Clients Name

Referrer Name *

Referrer Phone Number *

Referrer Email *

Terms and Conditions

I have read and consent to the Cancellation Policy *

I consent for Optimum Health Solutions to obtain, release and discuss information that is relevant to the services being provided. This may include verbal and written communication regarding past and present treatment & services.

Key Parties may include, but are not limited to, some or all of the following:

• LAC/ NDIS Plan Coordinator
• Treating Medical Practitioner (GP) / Medical Specialists
• Other Allied Health Professionals
• Support Coordinators/Case Coordinators
• Relevant Support Workers/ Key Support Workers
• Service Providers/Suppliers
• Immediate Family Member
• Guardians/Power of Attorney/Participant Nominated Representative

*

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....

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

ABN

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

Clinic Contact Information

Batemans Bay - 02 8064 9105

batemansbayclinic@opt.net.au

3/34 Orient Street

Batemans Bay

NSW 2536

Liverpool - 02 8599 6281

liverpoolclinic@opt.net.au

5/33 Heathcoate Road

Moorebank
NSW 2170

Blacktown - 02 8599 6275

blacktownclinic@opt.net.au

2/114 Main Street

Blacktown

NSW 2148

Campbelltown - 02 8599 6275

campbelltownclinic@opt.net.au

Inside Aquafit (Rehab)

Old Menangle Rd,

Campbelltown

NSW 2560

Speech Therapy & Occupational Therapy

25 Iolanthe Street

Campbelltown

NSW 2560

Cessnock - 02 4990 1046

cessnockclinic@opt.net.au

Unit 1, 384 Wollombi Road

Bellbird

NSW 2325

Croydon Park - 02 8599 6280

croydonclinic@opt.net.au

227 Georges River Road

Croydon Park

NSW 2133

Goulburn - 02 4810 0700

goulburnclinic@opt.net.au

37 Ross Street

Goulburn

NSW 2580

Hornsby - 02 4810 0700

hornsbyclinic@opt.net.au

Unit 6/30 Leighton Place

Hornsby

NSW, 2077

North Rocks - 02 9053 2997

northrocksclinic@opt.net.au

22 Loyalty Rd

North Rocks

NSW 2151

Nowra - 02 4445 3700

nowraclinic@opt.net.au

8/38-44 Berry Street

Nowra

NSW 2541

Sylvania - 02 8064 9105

sylvaniaclinic@opt.net.au

1/266 Princes Highway

Sylvania

NSW 2224

TAS - 03 6245 0799

tasmaniaclinic@opt.net.au

Mornington

49 Electra Place
Mornington
TAS 7018

Moonah

71 Main Road
Moonah
TAS 7009

Dodges Ferry

517 Old Forcett Road
Dodges Ferry
TAS 7173

Save and Complete Later