Intake Form Adult

New Client Intake Form

Your details

Your Full Name *

What is your relationship to the participant:

Participant Information

Participants first name: *

Participants last name *

Date of Birth *

Participants Address *

Current Diagnosis and Medical conditions (if any) *

Current Medications (if any) *

Family members living at home (please include names and ages) *

Are there any Family Law Proceedings we should be made aware of? *

YesNo

Goals for sessions

Priority 1 Goal (please include as much detail as possible) *

Priority 2 Goal *

Priority 3 Goal

Other comments/ areas of concern (list if necessary)

Participant History

GP Name, clinic and contact details

Please note name and contact details

Any known allergies *

YesNo

What is your child allergic to? (if any)

In Case of Emergency

Contact Name *

Contact number *

Relationship to the participant *

NDIS Participant Information

NDIS Participant Number *

Funding type *

Plan managedSelf managed

Plan Manager Contact details

Declaration and Consent Forms

By using your electronic signature to sign this document, you declare you are the participant/ participants representative *

YesNo

By using your electronic signature to sign this document, you consent in full to the sharing of history, personal details, diagnostic results and clinical observations with other providers (as noted in participants history) *

YesNo

Please note any exceptions to your consent to share information

By using your electronic signature to sign this document you consent to commencing services with Therapy Assistance and Support Services *

YesNo

By using your electronic signature to sign this document you agree to pay for Therapy Assistant and Support services as per the payment policy in the Service agreement *

YesNo

By using your electronic signature to sign this document, you understand that sessions cancelled late (with less than 24 hours notice) or that are not attended without notice are billed for the full cost of the session including travel and other associated costs *

YesNo

By using your electronic signature to sign this document, you consent to photos of you being used on Therapy Assistance and Support Services social media *

YesNo

Participant/ participant representative's Signature

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Full Name *

Today's Date

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