Client Consent and Contact Details Form

Client Details and Consent Form

All new clients, please complete this form for our records before your initial appointment.
  • Client Details

  • Include reference number
  • If "Yes' please provide details
  • Please provide the following information for any other guardians or case workers involved with your child. Please include organisation, case workers name, phone and email contact details, relevant placement history and indicate if the child is placed with you on a permanent or temporary basis.
  • NDIS Information (if applicable)

    Please complete the following information if you or your child are accessing funding under the National Disability Insurance Scheme. This information is required as part of our obligations to the NDIA and to assist us in claiming funds from your budget.
  • Please provide the details below of the agency managing your NDIS plan, including support coordinator name and contact details.
  • A Service Agreement will be provided to you either at the time of your initial appointment, or beforehand via post or email. This contract is a legal obligation as NDIS service providers, outlining our obligations to you and our requirements regarding fees and appointments. For clients whose budgets are NDIA managed, we are required to make a Service Booking on your behalf in the NDIS portal which sets aside funds to be used for All Abilities services. Do you give permission for All Abilities to create a service booking to cover the costs of your initial assessment (billed at a rate of $175 per hour)? Any further funds required will be discussed with you at your initial appointment. Please note an in-clinic assessment is estimated to take 1-2 hours. A home-modifications or daily living assessment taking place in your home is estimated to take around 5 hours depending on travel times required.
  • Consent Details

  • The undersigned confirm/s that he/she is the legal guardian/s for the above mentioned child and/or are authorised to act on behalf of the child in the capacity of authorising All Abilities in their management.
  • All Abilities Therapy and Support Services needs to collect information about you/your child for the primary purpose of providing a quality service to you/your child. In order to thoroughly assess, diagnose and provide therapy, we need to collect some personal information from you about you / your child. If you do not provide this information; we may be unable to treat you/your child. This information will also be used for: a) The administrative purposes of running the practice; b) Billing either directly or through an insurer or compensation agency; c) Use within the practice if passing your case to another speech pathologist within the practice for your/your child’s ongoing management; d) Disclosure of information to your/your child’s doctors, other health professionals or to teachers to facilitate communication and best possible care for you/your child; and e) In the case of insurance or compensation claim it may be necessary to disclose and/or collect information that affects your return to work. f) If it is subpoenaed by court g) Failure to disclose the information would place you, your child or another person at risk h) Mandatory reporting relating to child abuse or family violence is necessary; i) Your prior approval has been obtained to discuss the matter We do not disclose your personal information to overseas recipients. All Abilities Therapy and Support Services has a Privacy Policy that is available on request, at www.allabilitiestherapy.com.au and is available in the waiting area. This policy provides guidelines on the collection, use, disclosure and security of your/your child’s information. The Privacy Policy contains information on how you may request access to, and correction of, your/your child’s personal information and how you may complain about a breach of your/your child’s privacy and how we will deal with such a complaint. To ensure the process of quality treatment provision, information about your/your child’s assessment results and progress may be given to other relevant service providers, who are involved in your/your child’s management. These may include your/your child’s doctor, teachers, specialists, insurers, solicitors, employers or others, but only where it is considered to be of benefit to your/your child’s progress. The undersigned gives permission for All Abilities Therapy and Support Services to liaise with the following parties for the direct assistance of the child’s management:
  • I have read the above information and understand the reasons for collecting the information and the ways in which the information may be used. I understand that it is my choice as to what information I provide and that withholding or falsifying information might act against the best interests of my/my child’s assessment and therapy progress. I am aware that I can access my/my child’s personal and treatment information on request and if necessary, correct information that I believe to be inaccurate. I understand that if, in exceptional circumstances, access is denied for legitimate purposes, that the reasons for this and possible remedies will be made available to me. I understand that the Practice must obtain additional consent if the information collected is to be used in any ways other than that outlined above.
    All Abilities Therapy and Support Services aims to reduce the impact on the environment by providing information where possible via text or email. This includes provision of reports, updates and letters via email and the provision of appointment reminders via text. The undersigned hereby acknowledges that they have been informed of the use of email and text to communicate with parties and are responsible for ensuring that all information is updated. All Abilities Therapy and Support Services is not responsible for the provision of confidential information to another party in the case where the client / clients guardian has not provided up to date contact information.
  • All Abilities accepts private payments, Health Insurance, Medicare Plans (for rebates), FaHCSIA Funding and NDIS Funding. Rates may vary depending on funding arrangements, please contact All Abilities to confirm relevant pricing structure. Please note - Bulk Billing services are available with eligible Medicare care plans, however sessions are reduced to 20 minutes duration and this must be indicated upon booking your appointment. Regular appointments with a Medicare Plan run for 30 minutes and rebates can be processed in the clinic. Please indicate your payment method:
  • Clinical assessments are scheduled for up to 2 hours duration, depending on assessment type. Please note that during the assessment process, results may be obtained that require further investigation, in which case your therapist will discuss the completion of any additional assessment requirements. Where applicable, you will be provided with a summary report following your initial assessment. If you or your child has attended an assessment within 12 months of your initial appointment with All Abilities, you will not be required to attend an initial assessment, however you will be required to provide a report from this assessment. If your previous assessment is more than 12 months old or you do not have a copy of the previous assessment, you will be required to participate in a new assessment.
  • All Abilities will provide a summary report following each clients initial assessment. Your therapist will advise you at the conclusion of your assessment of the anticipated timeframe of report completion. Clients and parents/caregivers may request a progress report at any time. Please be advised a cost is associated with this which can be confirmed with your therapist. Your therapist will endeavour to complete this report within 2-3 weeks of it being requested.
  • Please be advised that the following cancellation fees apply to all clinic, home and school sessions: • Cancelling an appointment before 3pm the business day before the scheduled appointment - Free of Charge • Cancelling an appointment after 3pm the business day before the scheduled appointment OR failing to attend an appointment with no notice given – 90% of scheduled fee charged NDIS guidelines allow service providers to charge 6 hours worth of cancellation fees to your NDIS funding per year. Please be advised that any further cancellation fees incurred will not be able to be charged to your NDIS funding and will be payable by the Individual / Individual’s Representative. The Provider understands that people and/or their children get sick and so request you contact the clinic prior to the appointment and provide a medical certificate in order for the cancellation fee to be waived. A medical certificate is required to be supplied within 48 hours of the cancelled appointment. If you/your child is unable to make any scheduled appointment please call the office on 4731 3469. Please note that failing to attend two appointments within a 6 week period will result in the cancellation of any further scheduled appointments. Repeated cancellations within a 48 hour period (3 appointments within a 6 week period) will result in the cancellation of recurring appointments. You may call the office to reschedule appointments where there are times available.
    A quarterly newsletter is provided by All Abilities Therapy and Support Services, outlining any updates to our services including upcoming groups, networking and education opportunities, as well as blogs and resources written by our team of therapists. Do you give consent for All Abilities to email you a copy of our newsletter each quarter?
  • Family Information

  • School/Pre-School Information (if applicable)

  • Diagnostic Information

  • Referral Information