CLIENT DETAILS

First Name *

Last Name *

Address *

Suburb *

State *

Post Code *

Country *

Client Contact Number

Date of Birth *

Gender *

Cultural Considerations? *

MEDICAL HISTORY

Primary Diagnosis

Medical History / Summary *

GOALS & EXPECTATIONS

Clients Goals and Expectations for Services *

CLIENT REPRESENTATIVES

Full Name *

Relationship with Client *

Email Address *

Contact Number *

Does the Client have a Support Coordinator *

YesNo

Company Name *

Full Name *

Email Address *

Contact Number *

SUPPORT COORDINATION

Primary Contact for Confirmation of Services *

ClientClient RepresentativeSupport Coordinator

Primary Contact for Bookings *

Client RepresentativeSupport CoordinatorOther (Provide Details)

Full Name *

Contact Number *

Relationship to Client *

Emergency Contact *

Client RepresentativeSupport CoordinatorOther (Provide Details)

Full Name *

Contact Number *

Relationship to Client *

PAYMENT OF SERVICES

Funding Source *

Billing Full Name *

Billing Contact Number *

Billing Email *

NDIS Plan Manager Company Name *

NDIS Plan Manager Contact Name *

NDIS Plan Manager Contact Number *

NDIS Plan Manager Email *

NDIS Plan Number *

NDIS Plan Start Date *

NDIS Plan End Date *

Please upload your NDIS Plan

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Referring Doctors Full Name *

Referring Doctors Provider Number *

Number of Approved Sessions *

Referral Date *

Medicare Number *

Medicare Reference Number *

General Practitioners Referral Form. *

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Appointments can not be offered without the submission of the Clients, General Practitioners Referral Form. Please also note that RAR Therapy will not be responsible for claiming the Gap Payment for Services. Medicare Claim will be the responsibility of the Client and or Representative. Please use the Save for Later Option located at the bottom of this form should you need to come back and finalised at a later date.

SERVICE DELIVERY

Preferred Service Delivery Method *

Service Location *

Perferred Appointment Time *

Morning Appointment (8am-12pm)Afternoon Appointment (12pm-5pm)I will Accept Any Appointment Time OfferedBefore or After School ONLY Appointment

Appointment / Booking Considerations *

SERVICE REQUIREMENTS

Please Nominate Therapy Type Required *

Occupational TherapySpeech TherapyPsychologyPositive Behaviour Support

Occupational Therapy *

Speech Therapy *

Psychology *

Positive Behaviour Support *

Do you have any additional supporting documentation or previous reports you would like to submit? *

YesNo

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PRIVACY POLICY

I give consent to RAR Therapy to collect and use my personal and sensitive information as per the RAR Therapy Privacy Policy. *

HOW DID YOU HEAR ABOUT RAR THERAPY

Answer

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