Home Apply for Services Application for Serv... Application for Services Application for Services 1Service User2Contact Info3Legal4Services5Support Needs6Service Delivery7Funding8Disability & Health9Consents Service User Information The service user is the person who will be receiving therapy services.First Name* Surname* Preferred Name Gender:* Male Female Non-Binary Intersex Other/Unspecified Not known Date of Birth:*DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Pronouns He/Him/His She/Her/Hers They/Them/Theirs Country of Birth:*Please select...AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsIs the service user Aboriginal or Torres Strait Islander?*Please SelectNo knownAboriginal but not Torres Strait IslanderTorres Strait Islander but not AboriginalBoth Aboriginal and Torres Strait IslanderNeither Aboriginal nor Torres Strait IslanderResidential Address* Address Suburb Postcode Language Spoken:* English Interpreter Required?*Yes - for spoken language other than EnglishYes - for non-spoken communication (e.g Auslan)NoAre any immediate family members of the service user already receiving services from Therapy Focus?* Yes No Please list their full names*Use the + button to add another name Is the service user the main contact for this application and for service delivery?* Yes No Mobile* Home Phone Email address* Preferred method of contact*Preferred method of contactMobileEmailPhonePostDelivery Address Address Suburb Postcode Primary Contact This is the person we should contact about this application and during service delivery.First name* Surname* Preferred name Relationship to service user*Relationship to service userSpouse/partnerMotherFatherDaughterSonOther relativeFriend/neighbourFoster carerLegal guardianSupport worker/coordinatorMobile Home phone Email* Same residential address as service user?* Yes No Residential Address* Street Address City ZIP / Postal Code Preferred method of contact* Mobile Email Phone Post Postal Address* Street Address City ZIP / Postal Code Language Spoken:* English Interpreter Required?*Yes - for spoken language other than EnglishYes - for non-spoken communication (e.g Auslan)NoAlternative Contact This is the person we should contact if we can’t get in touch with the service user/primary contact.First Name* Surname* Preferred name Relationship to service user*Relationship to service userSpouse/partnerMotherFatherDaughterSonOther relativeFriend/neighbourFoster carerLegal guardianSupport worker/coordinatorMobile Home phone Email* Same residential address as service user?* Yes No Residential Address* Street Address City ZIP / Postal Code Preferred method of contact* Mobile Email Phone Post Postal Address* Postal Address Suburb Postcode Language Spoken:* English Interpreter Required?*Yes - for spoken language other than EnglishYes - for non-spoken communication (e.g Auslan)No Legal and GuardianshipHas the service user been appointed a legal guardian?* Yes No Is the primary contact the legal guardian?* Yes No Please select which of these orders are in place:* Administration Power of Attorney Enduring Power of Attorney Family Court Order Is there a Protection Order in place for the service user?Including a Police Order, Conduct Order or Family Violence Restraining Order Yes No Is the service user the person protected or the person of interest in the Order* Person protected Person of interest Legal Guardian* First Last Agency* Address* Postal Address Suburb Postcode Phone* Mobile* Email address* Language Spoken:* English Interpreter Required?*Yes - for spoken language other than EnglishYes - for non-spoken communication (e.g Auslan)NoPreferred method of contact* Mobile Phone Email Post Please upload any supporting legal documentation available to assist with processing of this application.File Drop files here or Select files Max. file size: 30 MB. ServicesPlease select the services you are requesting* Assistive technology Autism assessment Continence and toileting support Counselling Dietetics Functional assessment Home modifications Mealtime management Physiotherapy Positive behaviour support Psychology Occupational therapy Speech pathology Therapy Assistant Other/Unsure Autism AssessmentDoes the service user have a referral from GP or Paediatrician ?* Yes No Please note we require a referral to complete an Autism assessment.Please select what is required:* Comprehensive autism diagnostic assessment and report by a psychologist and speech pathologist. Speech Pathologist assessment only (Psychologist accessed elsewhere) Psychologist assessment only (Speech Pathologist accessed elsewhere) Continence and Toileting SupportDoes the service user ever go longer than 12 hours without passing urine?* Yes No Does the service user's urine appear cloudy, have any blood or an offensive odour?* Yes No Was the service user previously completely continent in urination, or have they always had issues urinating?* Previously continent Always had issues Does the service user use catheters, or has it been recomended they use catheters?* Yes No Is there blood in the service user's stool, or is it very dark in colour?* Yes No Does the service user ever pass stools so large they can't be flushed?* Yes No Has the service user experienced constipation from birth or early infancy?* Yes No Was the service user previously continent for faeces, or have they always had incontinence of faeces?* Previously continent Always had issues Does the service user ever go more than a week without opening their bowels?* Yes No Does the service user ever leak liquid stool?* Yes No Has the service user recently lost weight unexplainedly, or been diagnosed with failure to thrive?* Yes No Has the service user noticed any persistent stomach bloating?* Yes No Has the service user noticed a recent decline in leg function (i.e. tripping or falling more than usual, loss of sensation or feeling weak without reason)?* Yes No Counselling and Psychology All Psychology and Counselling services are delivered at the nearest clinic, via teletherapy or at school, as deemed appropriate. Does the service user have funding available under the Improved Daily Living category in their NDIS plan?* Yes No Hours available:*Please note: a minimum of 12 hours is required for ongoing psychology or counselling support.Unfortunately we are unable to provide positive counselling and psychology services unless you are choosing to pay for these services privately. Please continue this application and we will contact you to discuss payment options.Please select the reason(s) for referral* Anxiety Depression Trauma Sleep difficulties Emotional regulation (specific to mental health) Self esteem/confidence Relationship conflict Suicidal thoughts and behaviours (if current crisis/risk please contact your GP for immediate support) Non suicidal self injury/self harm Challenging behaviour (if primary concern, please request Positive Behaviour Support services)) Is the service user currently working with a psychologist, psychiatrist or social worker?* Yes No Please outline the type of service and frequency of appointments*Is the service user at risk of harm to themselves or others (now or in the past)?* Yes No Please provide details*Does the service user have any personal safety concerns, such as being harmed by others (now or in the past)?* Yes No Please provide details*Dietetics and Mealtime ManagementDoes the service user get red or watery eyes during mealtimes?* Yes No Does the service user often get food stuck in their throat?* Yes No Does the service user put their fingers in their mouth to clear food?* Yes No Does the service user require any texture modifications be made to their foods or drinks to make them safe?* Yes No Does the service user eat less than 20 foods, or have any nutrient deficiencies?* Yes No Home ModificationsPlease detail any existing modifications to the service user's home Positive Behaviour SupportDoes the service user have funding available under the Improved Relationships category in their NDIS plan?* Yes No Hours available:*Does the service user have funding under the Improved Daily Living category in their NDIS Plan, which we can use to conduct a short assessment and provide recommendations for future pathways and strategies to manage identified behaviours (10 hours required)? Yes No Unfortunately we are unable to provide positive counselling and psychology services unless you are choosing to pay for these services privately. Please continue this application and we will contact you to discuss payment options.Please detail any restrictive practices in place currentlyAny practice or intervention that has the effect of restricting the rights or freedom of movement of the service user. Functional Areas and Support NeedsPlease select the level of support required for the following functional areas:*Does not need support/supervisionSometimes needs support/supervisionAlways needs support/supervisionNot applicableEmotional regulationSocial skillsToiletingSelf-careMobilityCommunicationRelationshipsMealtimesLearningCommunity participationWork/Employment skillsIndependent living (15+ years)Please outline why therapy services are neededPlease list any services or supports the service user is currently accessingFor example, community groups, school supports, other service providers.Please list any equipment/assistive technology the service user currently hasPlease provide any supporting documentation available (e.g. diagnostic reports) to assist with processing of this application.File Drop files here or Select files Max. file size: 30 MB. Service DeliveryHow would you like services to be delivered? You may select more than one. Long-term therapy to achieve multiple goals Short block of therapy to achieve one goal One-off assessment Group therapy sessions Other/unsure Please select where you would like to receive services* Home School Work Therapy Focus office Community location Teletherapy School* School Address* Address Suburb Postcode Workplace* Work Address* Postal Address Suburb Postcode Therapy Focus office* Bassendean - 371 Collier Road Bentley - 6/1140 Albany Hwy Bunbury - 7 George Street Butler - 7/240 Butler Boulevard Ellenbrook - 3/8 Commercial Road Joondalup - 10 Elcar Lane Kwinana - Zone Youth Space, Gilmore Avenue Maddington - 5-6/1862 Albany Hwy Mandurah - Billy Dower Youth Centre, 41 Dower Street Margaret River - 111 Bussell Hwy Midland - 2/44 Mathoura Street Mirrabooka - 77 Honeywell Boulevard Osborne Park - 2 Neil Street Walliston - Walliston Primary School, 11 Dianella Road Yangebup 12/31 Moorhen Drive Community location* Community Location* Address Suburb Postcode Funding Please select which funding option you would like to use to access services:National Disability Insurance Scheme (NDIS) National Disability Insurance Scheme (NDIS) To access services using NDIS funding, the service user must meet NDIS eligibility criteria and have an approved NDIS Plan. Please refer to the NDIS website (ndis.gov.au) for information about eligibility.NDIS Participant number NDIS plan start date Day Month Year Please upload a copy of the service user's NDIS Plan. Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 5 MB. State Government Department for Communities' Disability Services State Government Department for Communities' Disability Services To access services using Department for Communities' Disability Services funding, the service user must already be receiving services from another provider with this funding.We will contact you for any required documentation.Self-funded Self-funded Individuals who are not eligible for Government funding can purchase our therapy services for a fee. Eligible individuals already accessing Government funded services are also welcome to purchase additional therapy services. Private health rebates may apply to some services.Private Health Insurance provider: Medicare Medicare Please upload a copy of your GP referral to access services under your Chronic Disease Management Plan or Mental Health Care Plan. Please note that Therapy Focus does not bulk-bill for services. This means that there will be a gap payable. You will be required to pay your account in full and make a claim from Medicare for services delivered.File Drop files here or Select files Max. file size: 30 MB. Disability What is the service user's disability? You may select more than one. (Leave this section blank if the service user does not have a disability)Disability Acquired brain injury Autism spectrum disorder (ASD) Cerebral palsy Deaf Deaf blind (dual sensory) Down syndrome Epilepsy Global developmental delay (GDD) Hard of hearing Intellectual disability Motor neurone disease Multiple sclerosis Muscular dystrophy Para/quadri(tetra)/hemiplegia Psychosocial disability Specific learning disability Speech impairment Spina bifida Stroke Vision impairment Other Please specify Health Has the service user experienced or currently experiencing any of the following? Please select all that are relevant.Health Anxiety, depression or other mental health concerns Aspiration (gagging, choking or recurrent chest infections) Difficulty swallowing during mealtimes Enteral/tube fed Faltering growth Pressure sores Recurrent falls / decline in mobility Self-harm behaviour or behaviour that puts other people at risk Seizures Significant pain or discomfort Tracheostomy / respiratory supports (O2, ventilations, suction) Unintended/unexplained weight gain or loss Upcoming planned surgery (within the next six months) Urinary catheter or stoma Other health concerns (please specify) Please provide details and/or examples of the above: Consents I consent to Therapy Focus collecting, using, and keeping my information as necessary for the purpose of providing services. * I consent to Therapy Focus collecting, using, and keeping my information as necessary for the purpose of providing services. I understand that I can withdraw or amend my consent at any time. * I understand that I can withdraw or amend my consent at any time. I understand that I can request to access and/or amend my information. * I understand that I can request to access and/or amend my information. I understand that Therapy Focus will take all reasonable steps to keep my information safe, and will not share my information without my consent, except as required for safety or legal reasons.* I understand that Therapy Focus will take all reasonable steps to keep my information safe, and will not share my information without my consent, except as required for safety or legal reasons. How did you hear about Therapy Focus?*Please select all that apply. Word of mouth/recommendation NDIS/Planner Support Worker or Coordinator GP/Paediatrician School Other service provider Google Social Media Advertising (i.e. newspaper, magazine, signage) Event or Expo Other Please specify: Storage, Access and Correction of Personal Information All Disability Professional Service Providers are bound by the Privacy Act 1988. As such, Therapy Focus undertakes to adhere to the Australian Privacy Principles; which regulate how we may collect, use, disclose and store personal information and how individuals may access and correct personal information held about them. For more information about how privacy is managed at Therapy Focus, please read our privacy policy.
