New Client Registration Form

First up, are you filling this form out on behalf of someone else. Please tick yes, if you are a parent or guardian.

Who is filling out this form?

I am the clientI am the guardian/carer filling this form for the client

If your child is under the age of 16, please click yes and fill out parent / guardian information.

Guardian/Carer Information

Guardian First Name *

Guardian Last Name *

Relationship to Client *

ParentSpouseSiblingFriendCarerOther

Guardian Email *

Mobile phone *

Client Details

Welcome to our clinic. We need to know a little about you before we can help. Please take 5 minutes to fill out this form and return it to reception when you’re done.

Title *

Client first name *

Client surname *

Preferred Name

Date of birth *

Pronouns *He/HimShe/herThey/them

Gender *

MaleFemaleTransNon-BinaryPrefer not to say

Sex Assigned at Birth *

MaleFemaleIntersex

Contact Email *

Mobile phone *

Address (Home)

Emergency Contact Information

Emergency contact *

Phone *

Relationship to Patient *ParentSpouseSiblingFriendOther

Background Information

Do you have any allergies *

YesNo

Please list allergies, if any

What services are you currently receiving?

PsychologistSpeech TherapyOTEarly InterventionAllied HealthCounsellor/ Social WorkerPsycho-therapistOther

If other, please specify

What services are you looking for? *

PsychologistSpeech TherapyOTEarly InterventionAllied HealthCounsellor/ Social WorkerPsycho-therapistGroup Programs

Legal Matters

Have you had any current contact with the police/ legal system or DFFH? *

YesNoOther

Please describe your history with the police/legal system/ DFFH *

Is there any family court orders, AVO's in place currently? *

YesNo

Please describe any court orders or AVO's in place *

Referral & Payment

How did you hear about us? *GPFriend/ FamilyWebsiteSocial MediaGoogleOther

Preferred Contact Method *

SMS & EmailEmailSMS

Do you have a Medicare Card *

YesNo

Are you billing under NDIS *

YesNo

How will you be funding the sessions? *

PrivateMedicareNDISTAC/ WorkcoverFASOther

Please specify how you will be funding the session *

General Practitioner Information

Do you have a current GP or specialist? *

YesNo

Do you have a mental health care plan? *

YesNo

Name of GP

Name of Clinic

Clinic Contact Number

Medicate Claiming

With a valid referral, you may be able to claim Medicare rebates on eligible services. Medicare claims will be submitted online on your behalf using client details provided on this form. Rebates will be deposited into the bank account you have registered with Medicare.

For clients under 16 years of age, a claimant is required for Medicare claims. The claimant is the individual who provides payment and receives the rebate in their bank account that is registered with Medicare.

Full Name of Claimant *This is person who is claiming money back from Medicare, not the child.

Claimant Date of Birth *

Medicare Card Number *The medicare card is the 10-digit number written across. Insert with no spaces.

Medicare Reference Number *What is the number of the patient on the Medicare Card

Medicare Card Expiry Date *

Concession

Do you have a concession card? *

YesNo

What is your CRN number?Centrelink Customer Reference Number (CRN)

NDIS Billing

NDIS Number

How is the plan managed?

NDIAPlan ManagedSelf Managed

Plan Start Date

Plan End Date

Plan Manager Provider Name

Billing Email

Consent

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

Signature *

Draw signature|Type signatureClear

Date *

Parent. Guardian Signature

Clear

Date *

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