Welcome to Family Time. Please take a few moments to complete this form so we can start our journey together.

Client Details

Please enter your child's name.

We'd love to get to know you!

Title

MrMissMaster

First Name *

Last Name *

Preferred Name

Please enter your child's date of birth & age.

Date of Birth *

Age *

What is your child's sex?

Sex *

MaleFemaleOther

Carer Details

Carer 1 Name *

Carer 1 Date of Birth *

Relationship to the Child *

Carer 1 Occupation *

Carer 1 Mobile *

Carer 1 Email Address *

Home Address

Address *

City *

State

Postcode

Country *

Secondary carer details

Carer 2 name

Carer 2 date of birth

Relationship to Child

Carer 2 occupation

Carer 2 Mobile

Carer 2 Email Address

Names and ages of siblings at home

Siblings/family members

School, Kindy or Childcare details

Name

Grade

Teacher

Medical information and Medicare details

Paediatrician

General Practitioner

Medical Centre

Medicare Number *

Parent Reference number *

Child Reference number *

Expiry *

How were you referred here?

Name *

Social Media *

Linked InInstagramFacebook

Following Therapists *

Drive by *

Googled

Details *

Cultural Background

What is your Cultural background?

What languages are spoken at home?

Diagnosis

Does your Child have a Diagnosis?

Diagnosis *

YesNoIn Progress

Details

Date of Diagnosis

By Whom

Details

Assessments and Funding

Have any previous assessments been completed?

Previous Assessment

Speech Pathology AssessmentOccupational Therapy AssessmentCognitive AssessmentOther

Details

Upload your previous assessments and/or relevant documentation

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National Disability Insurance Scheme (NDIS)

Do you have NDIS Funding?

YesNo

Please upload your current NDIS Plan

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There are a number of ways your NDIS Plan can be managed.

Self Managed:
The participant has chosen to self-manage the funding for NDIS supports provided under this Service Agreement. After providing those supports, the provider will send the participant an invoice for those supports for the participant to pay. The participant will pay the invoice on the day of service provision by EFTPOS or direct deposit.

Plan Managed:
The participant has nominated a Plan Management Provider to manage the funding for NDIS supports provided under this Service Agreement. After providing those supports, the provider will claim payments for those supports from the Plan Manager.

NDIS Plan Type

Self ManagedPlan Managed

Plan Manager Name

Plan Manager Email for Invoices

Emergency Details

Are there any emergency medical conditions or diagnosis we should be aware of?

Does your child have any allergies?

Does your child have any physical limitations or injuries?

Please provide an emergency contact

Name *

Phone Number *

Relationship to the Child *

Permission to call an ambulance if necessary:

If we can not be contacted in an emergency and it is deemed necessary I give permission for Family Time Australia to call an Ambulance. *

I acceptI do not accept

Authority to Release Information

I/We herby give my/our permission for Family Time to access personal details, relevant to your child/ren. Including any medical information and documentation on file that I/We have supplied or has been sent on behalf of us and/or said child/ren, including but not limited to Referrals, Letters, Assessments, Diagnosis, Treatment Notes and Recommendations and Funding Arrangements. I understand that the information will be treated confidentially and if it is published for statistical purposes in any way, it will not identify the child/ren or any other family member of our/my family. I understand that I may withdraw at any time in the future by giving written notice. *

I AcceptI do no Accept

Email & SMS Communication

Do you consent to receiving educational information and updates regarding Family Time via SMS?

YesNo

Do you consent to receiving educational information and updates regarding Family Time via email?

YesNo

Photo Consent Form

I agree that my child may be filmed or photographed for the following: – Programming and planning – Educational purposes – Advertising – Public notices including Television, Website, Facebook, Flyers or Newspaper

I AcceptI do not Accept

By electronically signing, I confirm the above information is true and correct

Your Signature

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