Primary Years Expression of Interest

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 *

Who is Referring you to us?

Name

Address

What is their Profession?

Email

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?

When did you notice them?

Have they become worse or stayed the same?

Please upload any reports

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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?

Which programs are you interested in accessing for your child?

Are you looking for assistance with your child's IEP or working with the school to negotiate a more harmonious approach to education?

Yes

Do you have an approved NDIS Plan?

Do you have an NDIS Plan in place?

YesNo

What are the plan dates?

Please upload your NDIS goals

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PRIVATE HEALTH INSURANCE

Will you be using private health insurance?

YesNo

Provider

COLLECTION OF DATA

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 agree with the Collection of Data Statement on behlaf of my child *

Signature of Parent/Guardian for Collection of Data *

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Signed on *

CONSENT

The Neurodiverse Playhouse needs to collect information about you for the primary purpose of providing a quality service to you. In order to thoroughly assess and provide therapy, we need to collect some personal information from you. If you do not provide this information, we may be unable to treat you.

This information will also be used for:

a. The administrative purpose of running the practice;

b. Billing either directly or through an insurer or compensation agency;

c. Use within the practice if discussing or passing your child’s case to another practitioner within the practice for

their ongoing management;

d. Disclosure of information to your doctors, other health professionals or to teachers to facilitate communication

and best possible care for you and your child; and

The Neurodiverse Playhouse has a Privacy Policy that is available on request and is available in the waiting area and on our website. That policy provides guidelines on the collection, use, disclosure and security of your information. The Privacy Policy 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.

To ensure the process of quality treatment provision, information about your assessment results and progress may be given to relevant other service providers, who are involved in your child’s management. These may include your child’s doctor, specialists, teacher, carers or insurers.

I have read the above information and understand the reasons for the collection of my child’s personal information and the ways in which the information may be used and disclosed and I agree to that use and disclosure.

• I understand that it is my choice as to what information I provide and that withholding or falsifying information might act against the best interests of my child’s assessment and therapy progress.

• I am aware that I can access my child’s personal and treatment information on request and if necessary, correct information that I believe to be inaccurate.

• I have been provided with or have been given an opportunity to obtain a copy of The Neurodiverse Playhouses' privacy policy.

I have read the above statement and give consent on behalf of my child *

Parent/Guardian Signature to provide consent *

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Today's Date *

SIGNATURE

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

Parent/ Guardian Signature *

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Today's Date

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