Contact | I.D.E.A. Therapy Services

Contact Details:

Name of Client

D.O.B

Parent/Carer Name

Relationship to Client

Mobile

Address

Language Spoken at Home

Interpreter Required

Yes

Funding Category (please highlight if any):

Funding Category

NDIS Funded (please fill out Section A)

Medicare/Chronic Disease Management Plan (CDMP) - please fill out Section B

Private

Other

Section A: Additional information if you are NDIS-Funded

Please check the most appropriate funding type:

Self-managed

Plan-managed

NDIS Plan Number

Plan Start/End Dates

NDIS contact (if any)

Requested amount of therapy hours (if known)

If you/your child is a participant with the NDIS it is required to have an approved service booking, prior to commencing services. A copy of your NDIS plan is also recommended to be provided prior to your first appointment.

Plan Management Details (please provide as many details as possible) - e.g - provider name and contact details

Medicare Funded

Medicare Number

Additional Information:

Relevant Medical History

Main Goal with Therapy

Other Important People

Other Associations

Service Location Preference

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