Client Registration & Consent Form NDIS Clients

CLIENT REGISTRATION AND CONSENT – NDIS CLIENTS

Child for Service: *
First
Last

Date of Birth *

Age *

Schooling level *
Pre-school
Primary School
High School

Parent or guardian name *

Do we have consent to share information with both parents? *

Address *
Address Line 1
City
State / Province / Region
Postal Code

Numbers *

Email *

Who referred you or suggested Connect Psychology? *

Does your child have a current NDIS Plan? *
If yes, how are you managing? Agency Portal/ Self managing/ Plan manager: name of Plan manager? * leave a not in the comment section at the end.

Comment or Message *

NDIS Number: *
Please note: you must provide the start and end date of your NDIS plan, Plan goals, and confirmation that the provision of the services that you have requested has been included in the plan. Services cannot be provided without this information.

Do you have a referral and Mental Health Care Plan from your GP, or a referral from your paediatrician, to also claim other Psychology services from Medicare? *
IF yes: Name of doctor referring: Please note: you must provide a copy of this referral before you are able to claim any Medicare rebates. Clients can use either Medicare OR NDIS, not both, for the same service.

Private health fund: *

Do you have extras cover? *

CONSENT TO RECEIVE SERVICES: *
Tick for consent
I have read and understood this form, and give consent for services to be provided to me/my child/my family. I accept the conditions outlined above, including payment conditions, and the terms as outlined in the Terms of Service. I accept that some services may be delivered by Telehealth where appropriate.

CONSENT TO SHARE INFORMATION: *
Tick for consent
I give consent for Jenni and her contractors/employees to obtain/release information with specified staff at my child’s school, specified DECD/ Catholic Education SA/AISSA staff, specified other professionals, and specified NDIS staff, for the purpose of planning and reviewing these services.

PARENT/ CAREGIVER PAYMENT AGREEMENT: *
Tick for consent
I understand and accept the fee structure that has been outlined to me, including session fees, travel costs, cancellation fees and payment arrangements. I understand and agree to the terms outlined in the Terms of Service document provided to me. If I am using NDIS funding, I accept that it is my responsibility to establish if there are sufficient funds to cover the costs of requested services provided by Jenni or her contractors and that there are funds available to make a Service Booking for requested services. I accept that I am personally responsible for the fees for any services not covered by NDIS, including services for which there were insufficient funds, services provided when no Plan was in place, fees not paid by a Plan manger when requested, and any costs incurred in recovering outstanding fees.

Please ask for a copy of our Terms of Service to be emailed to you. If you are unsure about any information on this form, please discuss with Jenni Pearce

Client Registration & Consent Form NDIS Clients

CLIENT REGISTRATION AND CONSENT – NDIS CLIENTS

Hyde Park

Collinswood

Aldgate

Hyde Park

Collinswood

Aldgate