New Client Information Contract


 

 

 

General Information

Child’s Name: Date of Birth: Age: Gender:  

Carer 1:

  • Relationship to Child:
  • Date of Birth:  
  • Occupation:
  • Mobile:
  • Email Address:  

Carer 2:

  • Relationship to Child:
  • Date of Birth:  
  • Occupation:
  • Mobile:
  • Email Address:  

Home Address: Suburb: State: Postcode:  

Name and age of other children/siblings at home:  

School/Preschool/Childcare details: Grade: Teacher:  

Paediatrician: General Practitioner: Clinic:  

Medicare Card Number: Parent Reference Number: Child’s Reference Number: Expiry:  

Diagnosis

Diagnosis: Details (if any): Date of Diagnosis: By Whom:  

Assessment

Previous Assessments Completed: Summary/Details of Assessments (if completed):  

National Disability Insurance Scheme Funding

I will access services through the National Disability Insurance Scheme (NDIS):  

If yes, my NDIS Plan is:  

Plan Manager Details:

  • Name:  
  • Contact Number:  
  • Contact Email:  
  • Invoice Email:  

Medicare

I will access services through Medicare:  

I have the following Medicare Plans and was referred by at

Private Funding

I will access services through private funding: . If yes, my private health insurance fund is:  

Emergency Contact Declaration

Emergency Medical Conditions/Diagnosis:  

Allergies:  

Physical Limitations or Injuries:  

In case of emergency please contact:

  • Emergency Contact Name:
  • Relationship to Child:
  • Phone Number:  

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

Authority to Release Information:

I/We herby give my/our permission for Family Time Australia 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.

Photo Consent

I agree that my child may be filmed or photographed during their class program for the following:

  • Programming and planning
  • Educational purposes
  • advertising or public notices including Television, Website, Facebook, Flyers or Newspaper.

Leave this empty:

Signature arrow

Signed by Family Time Australia
Signed On: August 27, 2020

Family Time Australia https://familytimeaustralia.com
Signature Certificate
Document name: New Client Information Contract
lock iconUnique Document ID: 448573c173d5a4d285448faedb6caab6ef299d3e
Timestamp Audit
July 4, 2020 12:28 pm ACSTNew Client Information Contract Uploaded by Family Time Australia - enrolments@familytimeaustralia.com IP 14.2.74.162