General Intake

Thank you for providing the following CONFIDENTIAL information to assist us in providing the safest and highest quality therapy for you possible. You have our assurance that the information gathered is used in accordance with our Privacy Policy, provided at the first session. Please call if you need help with this form.

Which therapist/s are you here to see? (please tick all that apply)

Make sure you select services before filling out the form. If you change your selection progress may be lost.

Client Details

Phone Numbers

School Details

Safety Details

Cultural Details

Funding Details

The following information is requested to assist us in keeping your out of pocket costs to a minimum.

+ Funding Types Information

Private – Payment required at time of service via cash or EFT, HICAPS also available.

Medicare – Please bring related paperwork to your initial appointment (eg EPC, Mental Health Care Plan).

Provider Managed NDIS – A copy of the clients current NDIS plan and or NDIS number is required at the client’s initial appointment. You will be required to fill out and sign a Service and Funding Agreement at your initial appointment, please call staff if you wish to fill this out/read prior to your appointment and we will email you a copy. If you have any questions regarding this please contact our office directly. Therapists will not treat clients that have not signed a Service and Funding Agreement.

Plan Managed NDIS – The details of your Plan Manager are required at your initial appointment. You will be required to fill out and sign a Service and at your initial appointment, please call staff if you wish to fill this out/read prior to your appointment and we will email you a copy. If you have any questions regarding this please contact our office directly. A therapist will not be able to treat clients that have not signed a Service Agreement.

Self-Managed NDIS – Payment is required at the time of service cash or EFT, a receipt will be provided for claiming. You will be required to fill out and sign a Service and Agreement at your initial appointment, please call staff if you wish to fill this out/read prior to your appointment and we will email you a copy. If you have any questions regarding this please contact our office directly. A therapist will not be able to treat clients that have not signed a Service and Agreement.

FACS – Clients funded by FACS must have a pre-approved purchase order before staring services at Spring Forward, please call our Accounts Department to discuss this further.

Important: If you have any type of funding, it is essential you bring a copy of all documentation (e.g. Letter of Introduction, Care Plan, etc) to your first appointment, or you will unfortunately be required to pay out of pocket. All EPC/CDMP/MHCPs MUST be filled out correctly including our centre name, number and type of sessions) or we will be legally unable to use them until they are corrected.

Referral Details

General Therapy Information

grommets, broken bones, etc.
parental health, up coming procedures, etc.

Feeding

Literacy

e.g. depression, distress, trauma to mother, relationship breakdown.

Medical History and Diagnoses

Milestones

Infant Gross Motor Milestones: Please list age completed (In months)

Preschool Gross Motor Milestones: Please list age completed (In years)

Other Physical Concerns

Location on body

Please read the Terms & Conditions and Privacy Policy.

Please make sure that all information provided is correct before submitting.