First Name:

Last Name:

Preferred Name:

Date of Birth:

Sex: Male Female Other

Address:

City/Town:

State/Region: New South Wales Victoria Queensland South Australia Western Australia Northern Territory Australian Capital Territory

Postal/Zipcode:

Country: Australia Other

Email Address:

Phone Number:

Occupation/Work:

Full Name:

Relationship:

Phone Number:

Are there any legal considerations that need to be considered (e.g., parenting orders, legal guardianship)? If yes, please state:

Current presentation, developmental delays, diagnosis and/or health conditions:

Upload Relevant Diagnostic Letters, Reports or Referrals:

Allergies:

Medications:

Upload Allergies and Medications Documentation:

NDIS Number (Please write N/A if not applicable):

NDIS Fund Management: Plan Managed Self Managed

NDIS Plan Start Date:

NDIS Plan End Date:

Email Address of Person/Company to Receive and Pay Invoices:

Please feel welcome to upload a copy of the NDIS plan or other relevant documents:

What goals are you wanting to work on?

Preferred Location of Appointments: Home School Visit Child Care Centre Telehealth

Please select the service providers you would like us to contact (select all that apply):
Physiotherapist
Occupational Therapist
School
General Practitioner (GP)
Specialist
Psychologist
Speech Therapist
Other (Please specify)

Preferred method of contact: Phone Email Post

Do you give consent for Flare Therapy to contact these service providers on your behalf?
Yes No

How did you hear about Flare Therapy?

Terms of Service: Please click on the link to the terms of service as it states the terms of service, including fees.

Upon submitting the form, your personal details will be sent securely to Flare Therapy. Please review and accept the privacy policy of Flare Therapy and click "I reviewed and I accept".

I have reviewed and accept the terms and privacy policy.

Signature:

Please draw your signature below:

Clear Signature

Date:

Kind regards,

Chris Armstrong
Occupational Therapist
Flare Therapy

www.Flaretherapy.com.au

ABN: 11741313662