Home Our Services Gaming Therapy Gaming Therapy Group... Gaming Therapy Group Registration Form 1Registrant Info2Participant Info3Group Info4Payment5Safety Planning6Terms & Conditions Registrant InformationYour name* First Last Phone*Email* Are you the person participating in the Gaming Therapy Group? (The participant) Yes No Are you the participant's parent or guardian? Yes No Participant InformatonThe participant is the person who will be attending Gaming Therapy group sessions.Full Name First Last Date of Birth* Day Month Year Preferred pronouns* She/Her He/His They/Them Is the participant currently receiving services from Therapy Focus?* Yes No, but they have previously No Parent/Guardian* First name Surname Emergency contact* First name Surname Relationship to participant* Phone* Group InformationHas the participant taken part in a Therapy Focus Gaming Therapy group previously?* Yes No What does the participant hope to achieve by attending this group?* PaymentHow would you like to pay for this group?*NDIS fundingPrivate purchaseDepartment of Communities/Continuation of supportNDIS Participant Number* How is your NDIS funding managed?* Agency managed Plan or Self-managed Do you consent to Therapy Focus creating a service booking under the participants name?* Yes No If you have already allocated NIDS funding to Therapy Focus, would you like to pay for this group out of those funds?* Yes No Billing DetailsName* First Last Phone*Email* Billing Address* Street Address City ZIP / Postal Code Safety PlanningAs a registered NDIS provider, Therapy Focus is required to collect the following plans and information.Does the participant have any of the following safety plans in place? Dysphagia/Mealtime management Behaviour support Seizure management Manual handling Transport Please upload a copy of all relevant safety plans Drop files here or Select files Accepted file types: jpg, doc, docx, png, pdf, Max. file size: 30 MB, Max. files: 5. Does the participant have any additional support needs that group facilitators should be aware of? Terms and Conditions Participants must pay for all group sessions If the participant needs to exit the group, or is unable to attend a session, we require two weeks' notice If the participant is absent and has not given two 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 Therapy Focus reserves the right to cancel the group if the minimum number of attendees is not achieved Agreement* I have read, understood and agree to these terms and conditions. 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. PhoneThis field is for validation purposes and should be left unchanged.
