Application for Services (ReFocus)

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:*
Pronouns
- He/Him/His
- She/Her/Hers
- They/Them/Theirs
Country of Birth:*
Is the service user Aboriginal or Torres Strait Islander?*
Residential Address*
Address Suburb Postcode
Language Spoken:*
- English
Interpreter Required?*
Are 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*
Delivery Address
Address Suburb Postcode

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Functional Areas and Support Needs

Please select the level of support required for the following functional areas:*

	Does not need support/supervision	Sometimes needs support/supervision	Always needs support/supervision	Not applicable
Emotional regulation
Social skills
Toileting
Self-care
Mobility
Communication
Relationships
Mealtimes
Learning
Community participation
Work/Employment skills
Independent living (15+ years)

Please outline why therapy services are needed
Please list any services or supports the service user is currently accessing
For example, community groups, school supports, other service providers.
Please list any equipment/assistive technology the service user currently has

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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

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
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Max. file size: 30 MB.

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What are you looking for?

Application for Services

Thank you for your interest in commencing services.

Service User Information

Primary Contact

Alternative Contact

Legal and Guardianship

Functional Areas and Support Needs

Funding

Disability

Health

Consents

Storage, Access and Correction of Personal Information