Intake form

Intake Form

Thank you for chosing Well-being Health and Movement to help you achieve your goals! We are very excited to be apart of your care team.

In order for us to have you on board as a client/patient, WHAM needs you to fill out this form and press submit once it has been completed.

You are welcome to print and handfill the form however, we will need you to take photos and send to admin@whamcare.com.au to be able to put you into our system before your first appointmennt.

This form may take you up to 15minutes to complete if you have all information on hand.

Thank you again!

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 *

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 PhysiologyDieteticsGroup Exercise ClassesPaediatric Dietetics (specialty and needs further information)

Are you able to come to our clinic? *

YesNo

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) *

Which class or classes are your hoping to attend? *

Strength: Tuesdays 2pm-3pmStrength: Thursdays 8am-9amBalance: Tuesdays 3pm-4pm

Other conditions that may be relevant

Paedatric Information

In order for us to be able to help you with your child's nutritional needs, we ask you to please fill out the following infomation so we can provide you more informed guidance from the first appointment.

Thank you for your help to allow us to understand your childs needs more comprehensively.

About Your Child

My child lives with *

My child's strengths and likes are *

My child's challenges and dislikes are *

The following helps my child feel calm and regulated *

Your Child's Development and Health

My child has the below developmental delay / challenge / disability: *

My child has these health conditions *

My child takes these medications and supplements *

Your Child's Care Team

Relevant details of my care team members (who they are and their contact details): *

I consent for my dietitian to communicate with my care team members when needed: *

YesNo

Your Child's Eating and Nutritional Challenges

What are your main concerns about your child's eating, feeding and/or nutrition? *

If your child struggles with eating - what has already been tried (by you or others), to help them?

Your Child's Weight and Growth

Do you have concerns about your child's weight / growth? *

Yes - slow weight gain / growthYes - rapid weight gain / growthNo

My child was born: *

Full termPremature (<=37 weeks)

Current weight (if known)

Current height (if known)

Your Child's Feeding History

Describe any early difficulties with solids OR when any feeding difficulties began: *

My child does a poo: *

Multiple times every dayDaily most of the timeIrregularly / every few days

Their poo:

Is often very runnyLooks normal but only comes out in small 'bits'Is painful and hard to passHas blood or mucus in itIs offensive smelling (more than normal poo) and/or they have really stinky fartsNone of the above

Your Child's Current Feeding/Eating

Food Allergies / Intolerances - please provide details:

Routine- my child: *

Has a definite meal / feeding routineIs a 'grazer' - constantly at the pantry/fridgeA bit of both

Breakfast *What and how much food and drink is consumed or given.

Morning Snack *What and how much food and drink is consumed or given.

Lunch *What and how much food and drink is consumed or given.

Afternoon Snack *What and how much food and drink is consumed or given.

Dinner *What and how much food and drink is consumed or given.

Evening Before Bed *What and how much food and drink is consumed or given.

Overnight *What and how much food and drink is consumed or given.

Drinks *

Favourite / accepted foods *

Avoided / difficult to eat foods *

My Child's Feeding Skills

Self feeding - my child: *

Doesn't self feed yetUses their fingers to eatUses a spoon / forkUses a knife to cut

Our Feeding Dynamics

Parents / main carers agree on how to feed this child: *

UsuallySometimesNeverN/A

How do you think mealtimes feel for your child? *

Mostly enjoyableJust OKStressful

Who is at meals with your child? *

The family (or at least one other adult) eats togetherSiblings (without adults)They are fed separately to everyone else

IPad / TV / other screens are: *

Necessary for my child to be able to eatSometimes on during mealsRarely/never on during meals

Other Comments

Comments

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, so that you can pay via bank transfer. Please advise us if the email for invoices is different below.

Our current pricing as of 1/7/2025 is;

Initial = $160

Follow up 1hr = $124

Follow up 45 mins = $109

Follow up 30 mins = $94

Group Classes = $15/class (please note we ask you pay for 50% of the 10 week-program upfront)

As part of our booking process, we securely collect your card details via our payment system, Tyro. This allows us to process payments for services provided if bank transfer has not been completed within 2 weeks of service, without explanation. It also allows us to charge the applicable fee in the event of a late cancellation or no-show, in accordance with our cancellation policy.

Your card details are stored securely and managed in compliance with industry standards for data protection. You will recieve a text message from Tyro to collect your card details. If you do not provide these, we will follow you up to collect them.

If you are receiving services under a funded scheme, we may still require your card details to cover late cancellations or to process payment prior to claiming any applicable rebates.

You have selected that you will be paying for our services via your NDIS funding. We will send any invoices to the nominated email address (depending on selection of self, plan or NDIA managed).

Our current pricing as of 1/1/2025 is in line with the NDIS Pricing Arrangement and Price Limits;

Exercise Physiologist = $166.99/hour (including GST)

Dietitian = $193.99/hour (GST free)

We currently can access the following codes respective of the practitioner providing the service;

Improved Daily Living

Improved Health and Wellbeing

Early Childhood Intervention

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.

We do not bulk bill. Our price list is below for your reference. Medicare will rebate you ~$60 per appointment. If our pricing is out of reach but you would still like to access us, we can offer payment plans or reduced prices for exceptional cases at our discretion.

Our current pricing as of 1/7/2025 is;

Initial = $160

Follow up 1hr= $124

Follow up 45 mins =$109

Follow up 30 mins = $94

If you are receiving services under a funded scheme, we may still require your card details to cover late cancellations or to process payment prior to claiming any applicable rebates.

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

If you are receiving services under a funded scheme, we may still require your card details to cover late cancellations or to process payment prior to claiming any applicable rebates.

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

Our current pricing as of 1/1/2025 is;

Initial = $160

Follow up 1hr = $124

Follow up 45 mins = $109

Follow up 30 mins = $94

If you are receiving services under a funded scheme, we may still require your card details to cover late cancellations or to process payment prior to claiming any applicable rebates.

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) *

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.

Will you be participating in or wish to participate in Hydrotherapy? *

YesNo

Other risks you would like identified *This could include things like; Limited vision, Deaf, Environmental factors, etc

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

In order for WHAM to maintain compliance and understand what parts of our therapy you consent to, we need you to select which clauses you consent to or not.

Please note that there are some questions that if you do not consent to, we may not be able to provide our services.

NDIS Specific Consent *

YesNo

I agree that auditors can look at my information when doing an NDIS audit.

YesNo

I understand my funding bodies might need to look at my information for an audit review.

YesNo

Medicare Specific Consent *

YesNo

I agree to allow my card details to be stored within "Tyro" to have my appointment billed in full, and await Medicare rebates

YesNo

I agree to pay cancellation fees, should I incur one

YesNo

Workers Compensation Specific Consent *

YesNo

I agree to allow my card details to be stored within "Tyro" to have my appointment billed in full, and await Medicare rebates

YesNo

I agree to pay cancellation fees, should I incur one

YesNo

I agree and understand that I need to be compliant with my treatment including but not limited to; completing home exercise programs, attending scheduled appointments (unless extenuating circumstances prevent you)

YesNo

DVA Specific Consent *

YesNo

I agree to allow my card details to be stored within "Tyro" to have my appointment billed in full, and await Medicare rebates

YesNo

I agree to pay cancellation fees, should I incur one

YesNo

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 my consent may be withdrawn at anytime but must be done in writing and sent to admin@whamcare.com.au

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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