Intake form

Intake Form

Client Details

Title *

First Name *

Last Name *

Preferred Name

Participant's Sex *

Date of Birth *

If you have selected other, please advise *

Client Email Address (not referrer email) *

Phone Number *

Emergency Contact Name

Emergency Contact Number

Participant Address *

Street address *

City *

State *

Postcode *

Emergency Contact Details

Name *

Relationship to you *

Contact phone number *

If you have selected other, please advise relationship to you *

Medical Details

GP Medical Centre *

GP Name

Reason for Referral/Treatment

Service Needed *

Exercise PhysiologyDieteticsBoth

Please provide the reason/s you are seeking treatment (what are your concerns and goals): *

Please list all medical conditions (if applicable. If no medical condition, please write n/a) *

Please list any mental health conditions (if applicable, if no mental health condition, please write n/a) *

Safety of Client and Practitioner

To ensure that we can keep the client and practitioner safe, we ask you to please complete this risk assessment.

E.g. aggressive dog, drug or alcohol misuse, difficulty parking, loose stairs or any other things we need to be aware of. *

Funding Details

Please select how you are funded *

You have selected that you will be paying for our services out-of-pocket. We will send any invoices to your nominated email address. Please advise us if the email for invoices is different below.

A referral is required for us to be able to see you. Please provide us with your referral form so we can book you in promptly.

A certificate of capacity is required from your GP prior to sessions commencing. Please ensure you have this prior to your first session.

We will send you a receipt once payment has been made in full to claim via your private health insurance.

Do you need to provide us with a different email address for invoices? *

YesNo

Medicare Number *

Reference Number *

Expiry (mm/yyyy) *

Email address for invoices *

DVA Number *

Colour of DVA card *

Workers Compensation Claim Number *

Date of injury *

Claim Manager's Name *

Claim Manager's Email Address *

Claim Manager's Contact Number *

Referrer's email *

Referrer's name *

Email for invoices *

HCP Level *

STRC start and end dates *

NDIS Number *

NDIS Plan Dates (start date and end date). Please ensure you give the year the plan starts and ends. *

Which bucket/item code do you need us to bill under? *

How much funding is available/ would you like to allocate to our services *

Do you have a support coordinator? *

Support Coordinator Name *

Support Coordinator Email Address *

Support Coordinator's Company *

Are you self or plan managed? *

Plan Manager Company *

Plan Manager Email Address *

Email for invoices (self managed) *

Upload your referral *

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Please upload your certificate of capacity (if you have it)

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Please upload the MAC report *

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Please upload your NDIS plan/goals

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If you would rather, you can list your NDIS goals below instead of uploading your plan.

NDIS Goals (if not uploading plan)

Late Cancellation Policy

WHAM has a 24-hour late cancellation policy in place. This policy ensures that you understand and aware that we will charge for late cancellations and no-shows within 24 hours of your scheduled appointment.

We cannot charge this fee by using a third party source of funding (e.g. DVA, Workers Compensation or CDM plan), this is solely payable by you. We understand that sometimes things arise, and will take this into consideration.

I understand that WHAM has a cancellation policy that states;
'If the client provides notice of cancellation via the appropriate channels but does so within 24 hours of their appointment, the participant will incur a cancellation fee equal to 100% of the service they are being provided.'
AND
'If the client makes no contact through any of the channels, and our therapist begins to travel or has arrived at the predetermined location for the service, both a 100% cancellation fee and a travel charge will apply. This also includes if the therapist arrives and the client contacts us at the time of their scheduled appointment or after the fact, to inform us they will not be attending'

You are liable for this charge and acknowledge that you have read the above.

Who is acknowledging the late cancellation policy *

ReferrerClientOther (Family member/friend etc.)

I am a relation/friend/carer for the above mentioned client and will advise the client and ensure that they understand that WHAM has a late cancellation policy in place.

I am a referrer for the above mentioned client and will advise the client and ensure that they understand that WHAM has a late cancellation policy in place.

What is your relation to the client? *

Name of person acknowledging this policy *

Patient Consent

I hereby give my permission for the release of my information to my Doctor, NDIS team, insurance company, or other allied health professionals, if required to assist with my treatment. I confirm that I have answered all questions truthfully to the best of my knowledge and will update WHAM or my Practitioner directly if these details change. I understand that if I have selected Private Payer, that all invoices will be sent to the email listed.

The patient has understood the above. (if you are referring on behalf of the patient, please ensure they have read and understood before checking this box) *

Who filled out this form? *

Relation to patient *

Name of person signing this form *

Is the patient under 16 years old? *

Please upload any results/reports that you think we may need!

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Signature *

Clear

Parent/Guardian Signature *

Clear

Date of signing

Please verify that you are human. *

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