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OT Individual Private Client Form
OT Client Form - Individual Private
Referral Date
DD slash MM slash YYYY
Sessions
Weekly
Fortnightly
Name
(Required)
First
Last
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone
(Required)
Email
(Required)
Date of Birth
(Required)
DD slash MM slash YYYY
Gender
(Required)
Male
Female
Other
Does the client identify as:
Aboriginal
Torres Strait Islander
Both
Other
Is an interpreter required?
(Required)
Yes
No
Does the client have a disability?
(Required)
Yes
No
Please list any specific supports required:
Are there any safety issues to be considered?
(Required)
Yes
No
Please detail any safety issues:
Is there any separation / Family Court involvement?
(Required)
Yes
No
Please provide details:
For children/young adults or clients with a carer:
Parent/Guardian/Carer Name:
First
Last
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Email
Will this person be responsible for transporting the client to/from sessions?
Yes
No
Name
Full Name
Phone
Relationship to Client
Emergency Contact Details:
Name
(Required)
First
Last
Phone
(Required)
Occupational Therapy Requirements
Have assessments been previously completed?
Yes
No
If so, and you are happy to share these, please send along with referral.
Primary reason/goals for referral:
Regulation
Sensory Needs
Eating
Toileting
Self Care
Play/social skills
Fine motor skills
Writing
Gross Motor/Coordination
Other/further details:
Invoicing Details
Name
(Required)
First
Last
Phone
(Required)
Email
(Required)
Consent
(Required)
I agree to the contract policy.
Confidentiality
Everything you share with your therapist is confidential. However, there are specific circumstances in which your therapist may have a duty of care to share information. These circumstances include:
• If your therapist considers you to be at serious risk of harm either to yourself or others
• If your counselling records have been requested by a court of law
• If another party or agency has requested your information, and you have agreed and provided your written consent to this.
Sessions
All appointments are 50 – 60 minutes duration. This is your time where you work with your therapist in a safe space to discuss or work through the issues you choose. Appointments are usually weekly, but in some circumstances fortnightly arrangements can be made.
Payments & Cancellations
Each appointment is $160. Payment methods include cash, EFTPOS or credit card. Late cancellation fees are payable with the following notice periods:
• Less than 24 hours – full session fee payable
• 24-48 hours – 50% of session fee is payable
• If two cancellations occur in a row we will need to withdraw our service as we are unable to allocate your allocated time slot to another.
Record Keeping
Your therapist may or may not take notes during your session. They will, however, always record notes afterwards. These are called case notes and are a mandatory requirement of our practice. Case notes are stored online within a secure document program called Power Diary. All written notes are shredded as soon as they are transferred into Power Diary. All client records are kept, as required by law, for a period of 7 years. For children, once they turn 18, their records are kept for 7 years from the date of their last contact with the service.
Email & Telephone Contact
Email and telephone contact with your therapist is limited to practical arrangements only. Your therapist is not permitted to enter into telephone or email therapy unless permission is provided in advance by the Principal Practitioner. If you are faced with a situation where you require an urgent appointment, please call the office to request an alternate appointment time 0414480934. Alternatively, contact Lifeline on 13 11 14 or in a life-threatening situation call 000 without delay.
Ending Counselling
Normally, the end of therapy would be by mutual prior agreement. However, you have the right to end your sessions at any time. We would ask that you let your therapist know in advance when you anticipate your sessions ending. If you are unable to return, for any reason, please provide a minimum of 48 hours’ notice. If it is felt that our service is no longer appropriate, your therapist will discuss this with you and may make referrals to a more appropriate service.
Complaints Policy/Procedure
If you are unhappy with the service, you have received from an employee of Innate Therapies please follow our complaints process which can be uploaded from our website www.innatetherapies.com or email adminteam@innatethereapies.com and they can email you out a copy of our policy.
Digital Signature
(Required)
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Home
About Us
Downloadables
Our Services
Child Counselling
Adult Counselling
Relationship & Family Therapy
Supervision for Counsellors
Attachment and Trauma
Critical Incident Therapy
Outreach Services
Programs
Adult Programs
Childrens Programs
Booking Social Programs
Therapies
Therapies
Childrens Therapy
Adult Therapy
Relationship & Family Therapy
NDIS
Current Programs/Events
Blogs
Employment
Allied Health Practitioner
Counsellor Position
General Application
Student Placement
Contact
General Enquiry
Cairns Office
Innisfail Office
Registration Forms
Social and Emotional Programs Enquiry
Call Now
Call Now