Returning Client Agreement

Client Details

First Name *

Last Name *

Date of Birth *

Phone Number *

Email Address *

Funding Stream - Please select below

NDIS

NDIS Plan Number *

NDIS Plan Start Date *

NDIS Plan End Date *

Is your Plan a PACE Plan *

YesNoUnsure

How to Endorse OHS

Disciplines

Occupational Therapy

Speech Therapy

Physiotherapy

Dietetics

Exercise Physiology

Hydrotherapy

Occupational Therapy - Assessment

Speech Therapy - Assessment

Behaviour Supports

Early Childhood Intervention

Podiatry

Occupational Therapy

How much funding would you like to allocate to your Occupational Therapy (Minimum 1 hour at NDIS 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 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

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

OT Therapy Total

Occupational Assessments

What is included in Occupational Therapy Assessments

Functional Capacity Assessment In Clinic = $2715.86

Assistive Technology = $1939.90

Functional Capacity Assessment External = $2909.85

Supported Independent Living Assessment = $4655.76

Specialist Disability Accommodation Assessment (SDA) = $4267.78

Manual 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

Speech Therapy

How much funding would you like to allocate to your Speech Therapy? (Minimum 1 hour at NDIS 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 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 Therapy being drawn from 2? *

Improved Daily Living (CB Daily ActivitiesDaily 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 = $2909.85

Swallowing & MTMP Assessment Gold = $2909.85

Communication Assessment Silver = $2521.87

Swallowing & MTMP Assessment Silver = $2521.87

Communication Assessment Bronze = $1551.92

Swallowing & MTMP Assessment Bronze = $1551.92

Diagnostic Dyslexia Assessment = $3297.83

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 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 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 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 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 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 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 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 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 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? *

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 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 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 much funding would you like to allocate to your Behaviour Management Plan? (Minimum 1 hour at NDIS 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 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.

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

Behaviour Support PACEWhile 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.

SBIS Total

BMP Total

PACE SBIS Total

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 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

A risk assessment will be sent once this form is submited

ECI Total

Podiatry

How much funding would you like to allocate to your Podiatry? (Minimum 1 hour at NDIS 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 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? *

Contact Number *

Email address for invoicing *

Plan Managed Calc

NDIS Plan

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Please provide a copy of your NDIS Plan. Alternatively please bring a copy of your plan along to your appointment.

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 upload a copy of your EPC *

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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 .

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

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 *

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Insurance

Claim Number

Date of Injury

Insurance Case Manager *

Phone number of Case Manager *

Case Managers email address *

Approval Letter *

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Any Additional Documentation

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

Communication Consent

Please select if you would like to receive.

SMS RemindersSMS MarketingEmail RemindersEmail Marketing

How did you hear about us?

Total Service Agreement Amount

Total Amount

Agreement signatures

I have read the terms and conditions

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Pre-Paid Policy *

Cancellation Policy *

Participant/Participant's Representative

Name

I have a Public Guardian in place

Public Guardian Email address

Authorisation

If you do not have permission to sign on behalf of the participant please select the save and continue link below. A copy of your form will be emailed to you and you can forward to the participant for signature. You will need to prompt them to un select the the I do not have permission to sign on behalf of the participant" so the submit button will appear. They can sign and click submit and a copy of the form will be sent straight to intake. If the form is submitted without a signature we will not be able to process this and a new form will be sent out to the participant.

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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

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