New Client Information Form

Below is the new client information form for Gotcha Covered! Support Services. This form is completely digital. We greatly appreciate this being filled out prior to your first meeting.

You may request a physical copy be sent to you by emailing us at accounts@gotcha-covered.com.au.

Participant's Information

Participant's Name

Date of Birth

Gender

Guardian's Name

Relationship to Participant

Contact Number

Address

Email Address

School/Preschool

Reason for Referral

Diagnosis

Paediatrician/GP

Other Allied Health Professionals

Medicare Details:
Name on Card

Card Number

Card Reference

Expiry Date

Requested Services at Gotcha Covered! Support Services:
Occupational Therapy (Assessment, individual and group therapy sessions including physical/phone/video consultations, reporting and planning, travel, liaising with required support personnel).Therapy Assistant (Individual and group therapy sessions, reporting and communication with parents and support personnel).Support Worker (Social and community access sessions (individual and group), reporting and communication with parents and support personnel).

**Service prices are subject to current NDIS NSW/VIC pricing guidelines (Dec 2020), prices are subject to change to reflect current NDIS pricing guide.

Current Funding:
Private PaymentNDIS (Self-Managed)NDIS (Planner-Managed)

I agree to pay my account in full in a timely manner:
YesNo

Participant Responsibilities

I am aware that sessions alone may not be sufficient to demonstrate progress. Therefore, I agree to actively participate in the intervention sessions and understand that Gotcha Covered! Support Services may recommend additional activities outside of sessions.

I will advise Gotcha Covered! Support Services of any changes to my personal details (contact number, address) or details of my NDIS plan (additional allied health professionals involvement, plan amendments etc.).

I understand that it is my responsibility to inform Gotcha Covered! Support Services as soon as possible but at the latest 12 hours prior to the appointment, if the participant is unable to attend sessions. If cancellations or failure to attend occurs, 90% of that appointment fee will be charged. Please note: up to 6 hours of cancellation fees may be charged.

I am aware that I can cease intervention services at any time. I commit to advise Gotcha Covered! Support Services if I intend to leave the service and that already provided services will be invoiced and I commit to pay them within 2 weeks.

I agreed to complete payment via direct deposit to Gotcha Covered! Support Services, following each session being completed in a timely manner.

Each appointment will include 15 minutes of documenting and planning as a standard fee. Any additional services such as communication with other stakeholders or resource production (e.g. visuals, social story) will incur additional costs.

I give general consent to Gotcha Covered! Support Services to obtain and release information regarding my child with other individuals/agencies associated with the education and care of my child, including day care, preschool, school, general practitioner, paediatrician, specialist or other allied health professional.
YesNo

How did you hear about us?

Guardian/Parent:
I understand and agree with the information provided by this intake form.

Guardian Name

Date Signed

Signature (Drawn In The Box Below)

Please attach any relevant or supporting documentation.
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