Tele-Transition Program Registration

Participant name*
First Last
Participant date of birth*
Participants email*
Participants phone*
Is the participant a Therapy Focus customer?*
- Yes
- No
Is the participant the primary contact for this application?*
- Yes
- No
Primary contacts name*
First Last
Primary contacts phone*
Primary contacts email*
Is the primary contact also the emergency contact for the participant?*
- Yes
- No
Emergency contacts name*
First Last
Emergency contacts phone*

Safety Planning
As an NDIS registered provider we are required to collect the following reports, where they apply to a customer receiving services from Therapy Focus.
Does the participant have any of the following safety plans in place?*
- Dysphagia/Mealtime management
- Behaviour support
- Seizure management
- Manual handling
- Transport
- No safety plans in place
Select all that apply.
You indicated the participant has one (1) or more safety plans in place. Please upload all relevant safety plans.*
Drop files here or

Accepted file types: jpg, doc, docx, png, pdf, Max. file size: 30 MB, Max. files: 5.
Please provide details*

Consents and Agreements
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, digital 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.
Comments
This field is for validation purposes and should be left unchanged.

Tele-Transition