New Client Information Contract
Child's Name: Date of Birth: Age: Gender:
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: Details (if any): Date of Diagnosis: By Whom:
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:
I will access services through Medicare:
I have the following Medicare Plans and was referred by at
I will access services through private funding: . If yes, my private health insurance fund is:
Emergency Contact Declaration
Emergency Medical Conditions/Diagnosis:
Physical Limitations or Injuries:
In case of emergency please contact:
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.
I agree that my child may be filmed or photographed during their class program for the following:
Leave this empty:
Your legal name
Your email address
Signed by Family Time Australia
Signed On: August 27, 2020
If you have questions about the contents of this document, you can email the document owner.
Document Name: New Client Information Contract
Agree & Sign