NDIS funded Initial Intake Form

This form is required to be filled out if you are seeking to have your initial parent consultation funded by NDIS funding.

Once this form has been completed, we will be in touch to arrange a suitable appointment time.

Location *

PaddingtonBanyoYarraville

CHILD DETAILS

MissMsMxMaster

First Name *

Last Name *

Preferred Name

Date of Birth *

Gender

MaleFemaleNon Binary

ATSI

AboriginalTorres Strait IslanderNone of the Above

PARENT CONTACT DETAILS

Parent Name *

Mobile Phone *

Email *

Address *

City / Suburb *

State *

Postcode *

DIAGNOSES

Do you have any diagnoses for your child? Who has provided these diagnoses? *

If you do not have a diagnosis or diagnoses, what are your concerns?

Therapies

Has your child engaged in any therapies? If yes, which therapies and with whom? *

If your child has engaged in other therapies, what strategies worked best for them? *

What didn't work for them? *

What are your child's goals for therapy?

What are your goals for your child's therapy?

Where would you like to see your child in 5 years?

Programs you are interested in

Which early intervention group programs are you interested in accessing?

Can you child follow two or more step instructions?

Do you have an approved NDIS Plan?

Do you have an NDIS Plan in place?

YesNo

Please upload your NDIS Plan *

Browse

Who is your Plan Manager? *

Contact Name:

Plan Manager Phone Number *

Plan Manager Email: *

Plan Manager Email for Invoices *

HOW WE WORK

At Neurodiverse Playhouse, our approach is deeply focused on understanding your child and your unique goals. The information you provide in this form serves as a vital foundation for tailoring our interventions to best suit your child's needs.

Participation in our programs is entirely at your own risk. While we have designed our activities to be safe and enjoyable for young children, we do not take any responsibility for injuries or accidents that may occur during participation. By participating, you acknowledge and agree that Neurodiverse Playhouse and its affiliates shall not be held liable for any injury or harm that may result.

Payment:

The client is liable for payment for this appointment. The fee is in line with NDIS price guide and is $193.99. Should your invoice be refused for payment by your plan manager or you do not have funding, you agree to pay for this appointment out of pocket.

Cancellation Policy:

In consideration of our waitlisted clients, we require at least 48 hours' notice for appointment cancellations. This allows us to offer the slot to another patient in need. Thank you for your understanding and cooperation.

COLLECTION OF DATA STATEMENT

The Neurodiverse Playhouse is an independent practice. You may contact The Neurdiverse Playhouse by writing to Neurodiverse Playhouse, 101 Turbot Street, Brisbane 4000 or by emailing letsplay@neurodiverseplayhouse.com.au. You have the right to gain access to the information held by The Neurodiverse Playhouse about you. Our Privacy Policy (available upon request) contains information on how you may request access to, and correction of, your personal information and how you may complain about a breach of your privacy and how we will deal with such a complaint.

Collection of Client information disclosure of client information:

The Neurodiverse Playhouse needs to collect information about you and your child for the primary purpose of providing quality treatment.

In order to fully assess and treat you and your child, we need to collect some personal information from you.

This information will also be used for the administrative purposes of running the practice such as billing you or through an insurer or compensation agency.

Information will be used within the practice for handover if another practitioner provides you with assistance.

Client information is stored securely and only practice staff has access to it.

The Neurodiverse Playhouse takes all reasonable steps to ensure that information collected about you and your child is accurate, complete and up-to-date

You may have access to your information on request and if you believe that any of the information is inaccurate, we may be able to amend it accordingly.

The Neurodiverse Playhouse may disclose information regarding assessments or treatment to your Doctor or other health providers only with your consent.

In the case of insurance claims, it may be necessary to disclose information and/or collect information that affects your treatment.

The Neurodiverse Playhouse will not disclose your information to commercial companies, however specific services or product information as supposed suitable for your management, may be forwarded to you by us, unless you instruct The Neurodiverse Playhouse not to forward this type of information.

Your written consent will be obtained at the start of your treatment in order to carry out the above activities. We do not disclose your personal information to overseas recipients.

If you do not provide relevant personal or health information, in part or in full, to The Neurodiverse Playhouse it may result in incomplete assessment. This may impact the following therapy that is provided.

Any concerns that you may have about this statement or about your management can be directed to The Clinical Director, letsplay@neurodiverseplayhouse.com.au

I have read and understand the above *

Parents/Guardian Signature *

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Date *

SIGNATURE

I confirm that above information I have provided is true, complete and accurate. *

Patient/ Guardian Signature

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