Sprout Health - Client Intake Form

Client Intake Form

Title *

Child's First Name *

Child's Last Name *

Child's Date of Birth *

Caregiver's Name *

Caregiver's Phone Number *

Caregiver:

Caregiver Phone Number:

Email Address *

Home Address *

How did you hear about us? *

Method of Payment - Private

Private Private - EPC plan *Private - Private Health

* An EPC plan is a plan provided by your GP entitling you to five therapy sessions per calendar year. This entitles you to receive a rebate of $58 off the private consultation cost through Medicare.

Method of Payment - NDIS

NDIS - Self-ManagedNDIS - Plan Managed

We do not currently accept NDIA managed participants.

If NDIS, please provide:

If you are supported by a plan manager, please provide their details:

Birth History: *

Medical History: *

Childhood Development: *

Does your child have trouble sleeping? *

Yes No

Preferred timing of day: *

Before schoolDuring school hoursAfter school hoursFlexible

Education details: *

SchoolDaycareN/A

If at school, name of school and year group:

Are you currently seeing other therapists? If so, please provide details:

What type of therapy are you looking for: *

Occupational TherapyPhysiotherapySpeech TherapyExercise Physiology

Does your child need help with any of these skills?

Is there any further relevant information you would like us to be aware of? *

Caregiver Consent

Please read the following and sign:

Practitioners in this practice will discuss your child’s condition and options for treatment with you so that you are appropriately informed and can make decisions relating to the treatment of your child. You may choose to consent to or refuse any form of treatment for any reason including religious or personal grounds. Once you have given consent, you may withdraw that consent at any time.

I have read & understand the above statement relating to consent for treatment. I offer my consent on behalf of my child to receive treatment within the practice. I agree to this consent remaining valid until such a time as I withdraw my consent.

I consent to photos being taken of my child during therapy sessions to be used for marketing purposes (website/social media) *

YesNoYes, but without face being visible

You will be shown a photo of your child before the photo is used.

Payment of our invoices

I accept responsibility for all treatment fees and will give 24 hours notice if unable to attend an appointment, otherwise a cancellation fee will be charged.

Parent Name: *

Date: *

Parent Signature *

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