Intake form

Intake Form

Client Details

Title *

First Name *

Last Name *

Preferred Name

Participant's Sex *

Date of Birth *

Client Email Address (not referrer email) *

Phone Number *

Participant Address *

Street address *

City *

State *

Postcode *

Emergency Contact Details

Name *

Relationship to you *

Contact phone number *

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 *

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.)

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? *

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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Date of signing

Please verify that you are human. *

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