I am completing this form for*
Myself as the participant Someone I am referring to Soaring Health
Participant Details
First Name*
Family Name*
Date Of Birth (dd/mm/yyyy)*
Gender*
Male Female Prefer Not to Say
Home Address
Participant Contact Number*
Participant NDIS Number*
Does the participant have a legal guardian / nominee?*
No Yes
Cultural Details
Participant Country of Birth*
Does the participant require an interpreter?*
--- Yes No
Language of required interpreter
Relevant culture or religious considerations(if any)?
Does the listed participant identify as an Aboriginal or Torres Strait islander?
No Yes
Services Request
Type of primary service required:*
--- Dietetics Hydrotherapy Occupational Therapy Physiotherapy Pilates (Clinical) Podiatry Psychology Speech Therapy (Pathology) Other
Please list the service(s) required*:
Number of hours requested for service ?:
Type of secondary service required:
--- Dietetics Hydrotherapy Occupational Therapy Physiotherapy Pilates (Clinical) Podiatry Psychology Speech Therapy (Pathology) Other
Please list service(s) required*:
Number of hours requested for service ?:
Additional service required:
--- Dietetics Hydrotherapy Occupational Therapy Physiotherapy Pilates (Clinical) Podiatry Psychology Speech Therapy (Pathology) Other
Please list service(s) required*:
Hours requested for additional service ?:
Participant's relevant conditions / disability (please list):
Participant behaviours or habits requiring special attention (if any):
Extra information that may assist with preparation for initial appointment:
Special assessments or therapies required:
Notes for Practitioners (additional relevant details):
Booking Details
Preferred consultation type/s:
In Clinic In Home Service Telehealth Community
Preferred clinic location:
Templestowe Lower Thomastown Craigieburn
Preferred community organisation:
School/kinder Respite Centre Community House
Who should we contact to make an appointment?
Participant/ Nominee Support Coordinator Other
Name:*
Relationship to participant:*
Mobile Number:*
Email:*
Notes for Reception Staff (if applicable):
NDIS Information
Participant’s NDIS Plan Type
NDIA Managed Plan Managed Self/ nominee-Managed
Plan Manager's Name:*
Plan Manager's Contact Number:*
Plan manager's email:*
Please upload NDIS Plan and relevant details (Maximum file size is 5MB)
Consent
The participant and those involved in the participant's care have read and understood Soaring Health’s current Cancellation Policy?*
Yes No
Note: Soaring Health will charge 100% of the full appointment booking if a cancellation occurs within 48 hours. This cancellation policy may change in line with NDIS guidelines.
The participant and those involved in the participant's care have read and understood Soaring Health’s current Travel Expense Policy?*
Yes No
Note: Soaring Health charges a maximum of 30 minutes for each way of travel. This is calculated from the nearest clinic to the participant’s home and billed at the standard rate of the practitioner. If we have multiple participants in your area, the total travel is divided among participants in the area. Travel charges may change in line with NDIS guidelines.
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