Home Our Services Gaming Therapy Gaming Therapy Appli... Gaming Therapy Apply for a group Complete this form to apply for Gaming Therapy. Step 1 of 3 33% Basic informationPlease have your NDIS plan ready, so you can easily complete this form. Participant name* First Last Participant Date of Birth* Day Month Year Is the participant a Therapy Focus customer?* Yes - currently receiving services Yes - previously received services No What are the participant's preferred pronouns?* She/Her He/Him They/Them Prefer not to say Parent/Guardian Name* First Last Phone*Email* Which Gaming Therapy game are you choosing?*MinecraftAnimal CrossingWhat is your preferred Minecraft dates/times?*16 - 19 January 2023 (10 - 18 Years) Ellenbrook/Online16, 17, 19 & 20 January 2023 (10 - 14 Years) Bentley17 - 19 January 2023 (8 - 12 Years) Mirrabooka17 - 20 January 2023 (11 - 16 Years) Butler23 - 25 January 2023 (13 - 18 Years) Mirrabooka23 - 25 January 2023 (12 - 18+ Years) Walliston23, 24, 25 & 27 January 2023 (6 - 10 Years) Butler30 January - 2 February 2023 (18 - 15 Years) ButlerWhat is your preferred Animal Crossing dates/times?*16 - 19 January 2023 (12+ Years) Walliston23, 24, 25 & 27 January 2023 (8 - 12 Years) WallistonEmergency contact 1 - Name* First Last Emergency contact 1 - Phone*Emergency contact 1 - Relationship to participant* E.g. Parent, Sibling, Carer, etcHas the participant taken part in a Therapy Focus Gaming Therapy session previously?* Yes No What is the participant's Minecraft username?* Therapy Focus uses a safe and secure server for Minecraft, the Minecraft username will allow Therapy Focus to add you to the server.What platform will the participant use to access Gaming Therapy?* Computer/Laptop Tablet Nintendo Switch XBOX PlayStation What are the participants goals for this group?* PaymentHow would you like to purchase this program?*NDIS fundingPrivate purchaseDepartment of Communities/Continuation of supportParticipant's NDIS Number* Do you consent to Therapy Focus creating a service booking under the participants name?* Yes No If you have already signed funds to Therapy Focus, would you like to pay for this group out of those funds?* Yes No How is your funding managed?* Plan or Self-managed Agency managed Do you consent to Therapy Focus charging up to a maximum of $1358 to the participants Improved Daily Living Budget to cover the cost of this group?* Yes No Please note, the charge of $1358 is a maximum based on a ratio of 1 therapist to 2 participants (1:2), where a group has a larger ratio (i.e. 1:3 or 1:4) the total cost will reduce.Do you consent to Therapy Focus writing you an invoice that states up to a maximum of $1358 to cover the cost of this group?* Yes No Please note, the charge of $1358 is a maximum based on a ratio of 1 therapist to 2 participants (1:2), where a group has a larger ratio (i.e. 1:3 or 1:4) the total cost will reduce.Do you consent to Therapy Focus writing you an invoice that states up to a maximum of $1155 to cover the cost of this group?* Yes No Please note, the charge of $1155 is a maximum based on a ratio of 1 therapist to 2 participants (1:2), where a group has a larger ratio (i.e. 1:3 or 1:4) the total cost will reduce. 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Terms and Conditions Participants must pay for all sessions If the participant needs to exit the group, or is unable to attend a group session, we require 2 weeks' notice. If the participant does not attend a group session and has not given 2 weeks' notice, the session will be charged The total cost of the group includes time spent for planning, travel and preparation If the participant requires 1:1 support this will be charged at the relevant hourly rate. We will request written approval for 1:1 support before charging you Therapy Focus reserves the right to cancel the group if the minimum number of attendees is not achieved I give consent for: the participant to be photographed/recorded for therapeutic and training purposes. the participant to be photographed/recorded for marketing/promotional purposes. Instances where photographs/recordings may appear include, but are not limited to; Therapy Focus Website, social media, digitial and printed publications. Agreement* I have read, understood and agree to these terms and conditions.By submitting this form you are agreeing to a placement in a group at your requested time. In the event these dates are full a staff member will be in contact to discuss other available sessions.Name* First Last Date*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920CommentsThis field is for validation purposes and should be left unchanged.
