NQNS Intake - Registration Form

NQNS Intake - Registration Form

To be completed by the referred individual or by an authorized representative
To proceed with a booking, it is a requirement to complete this Registration Form.

The form may seem lengthy, but it helps us help you! The information you share allows us to provide the best possible service, tailored to your individual needs.

If any questions do not apply, fill in N/A (not applicable) DO NOT LEAVE BLANK as incomplete forms will not be accepted.

Failure to complete this form may result in booking delay.

Please contact NQNS on 0418 717 211 if you require assistance completing this form.
Booking is requested for:

First NameLast Name
Date of birth

DayMonthYear
Address

Street Address

Street Address Line 2

SuburbState

Post code
Mobile number

Area codePhone Number
Home phone number

Area CodePhone Number
Email
example@example.com
Gender

MaleFemaleOther
Do you have a guardian or power of attorney? If so, Please list their details including name and contact number
Relationship status

SingleMarriedDefactoDivorced/SeparatedWidowedNot applicable
Work and Study - tick all that apply

UnemployedUnable to or exempt from workPart time or casual emplomentFull time employmentVolunteerPart time studentFull time studentRetired
Do you identify as*

AboriginalTorres Strait IslanderAboriginal and Torres Strait IslanderI do not wish to answerNone of the above
Nationality*
Language spoken at home
Name of next of kin*

First NameLast Name
Next of kin relationship*
Next of kin phone number

Area CodePhone Number
Next of kin email address
example@example.com
Emergency contact

First NameLast Name
Emergency contact relationship
Emergency contact Phone Number

Area CodePhone Number
Emergency contact email address
example@example.com
Regular GP (doctor)*
GP Practice name*
Reason for requesting booking. Please provide a brief background
Is neuropsychological assessment required for - tick relevant boxes

Strengths, weaknesses, severity of impairmentMonitor progress - baseline or review assessmentAssist with diagnosisCapacityCognitive, educational, intellectual/IQ assessmentNDIS purposesReturn to work and/or driveMedicolegal or insurance purposesPsychological assessmentOtherI'm not sure
Goal/desired outcome of assessment
Have you had any assessments or reports completed by the following? Tick all that apply

Previous NeuropsychologyOccupational TherapistSpeech PathologistPsychologistPsychiatristNeurologistBehavioural TherapistOtherI have not had any type of assessment
If available, please provide copies (multiple files can be uploaded) of relevant assessments/reports by uploading here:

Browse Files
Alternatively, please send to info@nqns.com.au Cancelof
If copies of assessments/reports are unavailable, please provide details. Include: Approximate date undertaken, where service was provided.
Do you have any medical conditions and/or diagnoses? If so, please list
Dominant Hand*

LeftRightAmbidextrous
How is your speech and language? Please provide details - e.g verbal/non verbal etc.
How is your hearing? Please provide details - e.g has not been tested, wears hearing aids etc.
How is your vision? Please provide details - e.g has not been tested, wears glasses, blindness etc.
How is your Mobility? Please provide details - e.g use of mobility aid/s, wheelchair, are you morbidly obese, an amputee etc.
Driving

I hold a drivers licenceI hold a drivers licence but do not currently driveCurrently not drivingI have never obtained a drivers licenceNot applicable
How do you typically engage during lengthy therapy/health related appointments? Tick all that apply

Openly, honestly and with as much effort as possibleI attend because I have toI get tired, fatigue can be a problemMy health and wellbeing is important, I'm happy to engageI find these types of appointments challengingI can be non-compliant and/or agressive at timesI don't mind, no issuesI may need to take some short breaksI'm not sure
Is there any family members, individuals or agency/s currently supporting your day to day needs and care? please provide details
Do you require transportation to attend the assessment? If so, please list details of the party providing transport
How will this assessment/service be funded?

Privately, I will pay with my own fundsA combination of my funds and private health insuranceNDIS - agency managedNDIS - plan managed or self managedNIISQWorkcoverAnother organisation is funding my serviceI'm not sure
If service is to be funded by an organisation, please provide as much detail as possible e.g. NDIS plan number, Workcover claim number, funding approval letter, support coordinator/case manager's details, organisation details.
Please list any other relevant information you wish to share related to this request for booking
Name and contact details of individual completing this form
Our practice is operating under a COVIDSafe plan. I agree to:*

Advise NQNS prior to any appointments of any possible symptoms within 10 days prior to your appointmentAdvise NQNS prior to any appointment if I am feeling unwell or have been in contact with a COVID positive case
Booking check list and acknowledgement

I have provided a formal written referral from a medical practitioner, service provider or organization - I understand without this, a booking cannot be madeWhere applicable, I have received information related to fees in the form of Informed Financial Consent documentFor PRIVATE PAYING CLIENTS ONLY - After referral is provided, I understand I have 1 week from the date of being contacted by NQNS about my appointment to sign my Informed Financial Consent and pay the deposit. Failure to do so will result in loss of booking date.I have read and acknowledge NQNS privacy policy documentI have read, understand, completed and signed a Service Agreement (if required)I have provided required documentation including: NDIS plan (if applicable), copies of relevant reports and assessments (if available)Booking deposit paid by due date. Only required for private paying, non organization funded bookings. Fully refundable if cancelled with required notice or if unforeseen circumstances occur.This Intake form is completed in full to the best of my knowledge
Signature

Clear
Date form completed

MonthDayYear
North Queensland Neuropsychology Service

PO Box 1113 Aitkenvale BC QLD 4814

www.nqns.com.au info@nqns.com.au

Ph: 0418717211 F: 07 44203812
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