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Waitlist Information Update 1Step One2Step Two3Step Three4Step Four5Step Five6Step Six7Step Seven Service User Information The service user is the person who will be receiving therapy services.First Name* Surname* Date of Birth:*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Are 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 Email* 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 confirm the services required. You may select more than one:* Autism assessment Assistive technology 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 How 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 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 PsychologyDoes the service user have funding available under the Improved Daily Living category in their NDIS plan?* Yes No Hours available:*Please note: aminimum 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.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 recomendations 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 and/or home modifications 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. 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. 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.
