New Client Intake Form

Client Name*

First NameMiddle NameLast Name

Preferred Name

Date of Birth*

DayMonthYear

Gender*

Ethnicity

Legal information *

Do you have legal parental responsibility? If not who does?

School child / young person / young adult attends:

(if applicable)

Interests *

Strengths *

What is your child / young person / young adult hoping to achieve?*

YesNo

If yes, please provide more details on reasoning.

Non swimmerBeginnerIntermediateAdvanced

Please tick all available options that your child / young person / young adult can attend.*

Rows	MORNING (9am - 12pm block)	MIDDAY (12pm - 3pm block)	AFTERNOON (3pm - 6pm block)	UNAVAILABLE ALL DAY
Monday
Tuesday
Wednesday
Thursday
Friday

WeeklyFortnightly

History

YesNo

If yes, please specify details.

YesNo

If yes, please specify details.

Note: Our Terms and Conditions below outline how we safely handle this information.

YesNo

If yes, please list it here:

*Please detail if we need to supervise this medication being taken.

Parent / Caregiver 1 / Guardian

Name:*

PrefixFirst NameLast Name

Relationship / Care Provider / Organisation

e.g. Maternal Grandmother, Father, Welfare Organisation

Phone Number:*

E-mail:*

Address:*

Street Address

Street Address Line 2

CityState

Post Code

Parent / Caregiver 2 / Guardian

(if applicable)

Name:

PrefixFirst NameLast Name

Relationship / Care Provider / Organisation

e.g. Maternal Grandmother, Father, Welfare Organisation

Phone Number:

E-mail:

Address:

Street Address

Street Address Line 2

CityState

Post Code

In Case Of Emergency

Emergency Contact:*

First NameLast Name

Relationship:*

Contact Number:*

Yes I understand and consentNo

Invoicing Details

Organisation Name:

Contact Name:*

First NameLast Name

Phone Number:*

E-mail for invoice to be sent to:*

Postal Address:*

Postal Address

Street Address Line 2

CityState

Post Code

If your child / young person / young adult has a NDIS number that you want quoted on invoices please provide it:

Fearless Terms of Service

These are our terms of service and your rights and responsibilities as the client and/or guardian/parent in relation to information security, access and confidentiality as well as obligations regarding fees, cancellations and the support you will receive.

Information and Security Access

Personal Information

All information obtained during treatment is kept confidential and secure, except when:

It is subpoenaed by a court.
Failure to disclose the information would place the client or another person at risk of harm.
Your (parent and/or your person where appropriate) prior approval has been obtained to:
- Provide a written report to another professional or agency; or
- Discuss the material with another person.

At times we are required to provide progress reports to Participants and the NDIA. This progress report outlines plan objectives and goals and whether goals are being met. A copy of our privacy policy can be given on request.

Information Security and Access

During our sessions personal information is collected to enable treatment. All notes taken during treatment and all communications relating to treatment become part of the clients’ clinical records. Clinical records are stored electronically in the client file on Halaxy, which you consent to or as a parent or client of this practice. You have a general right to access the client records (subject to some exceptions which mainly relate to privacy, health, child consent or legal considerations) and a request must be made in writing. You have a right to amend your records and personal information if incorrect. We are required to keep client personal information for 7 years after ceasing engagement with Fearless and up to age 25 years for a young person under the age of 18.

Your Responsibilities

Cancellation Policy

We understand that from time to time you may need to cancel your session with limited notice due to illness. We ask that you give us 72 hours’ notice in the event you need to cancel your session. This allows us to offer your timeslot to someone on our waitlist. We are always happy to try and schedule a makeup session during the term to make sure you / your child / young person gets the most out of their time with us.

Session Fees and Payment

Our session fees are $150 per hour (+GST if applicable). Travel is calculated on a KM and hourly rate and agreed to individually with you prior to session/s commencing.

PrivateSelf-Managed (NDIS)Plan Managed (NDIS)NDIA Managed (note we are unable to provide services at this time under this arrangement)

For Self-Managed (NDIS), Plan Managed (NDIS) and Private paying clients’ fees are payable within 7 days of invoice date. Should your client fees be outstanding for more than 2 weeks we will not continue to run further sessions with you until such time as the fees are paid and up to date.

Please note that if your NDIS plan does not have the required funds to pay for the service you agree that you will then be personally liable for the charges.

As a user of our service, you understand that in certain circumstances we are entitled to charge for expenses incurred in the provision of supports. These expenses include non-direct and non-face-to-face services including (but not limited to) Review Letters, Assessments, Progress Reports, Treatment Reports, Phone Calls, Clinical and Family Network Meetings and File Reviews.

Changes to this Agreement

Changes to this agreement can be made in writing when both parties agree to the changes.

Consent

Dear Parent / Caregiver / Guardian,

Working with children / young people / young adults presents certain issues and legislation that we must adhere to. The following clarifies where our role starts and ends. It also outlines our ethical and legal responsibilities regarding working with children / young people / young adults.

A child is defined as 'someone who is under 12 years of age' and a young person is defined as 'someone who is 12 years or older but not yet 18 years old'. A client-parent (or parents) is 'the person who engages Fearless to provide a service for a child / young person / young adult.

Whilst we do our best to communicate with the client-parent regarding the progress of the child / young person we cannot disclose any personal information unless we gain written consent from the client i.e., the child / young person, or they are deemed too young to understand these terms, disclosure to the client parent can then occur.

I give permission for {clientName} to attend ongoing appointments without my presence. I understand that I will still be required to be available via preferred mobile and email for communication about their treatment and progress with treatment.

We use person-centred therapy for our approach to counselling. If another therapy modality is going to be used this will be discussed with the client-parent and/or client (if applicable) before use.

Consent to Sharing Information

I give permission for Fearless to obtain and exchange appropriate written, electronic, or verbal information with the following persons/agencies:

If other/s, please specify:

Permission is given to share information until I withdraw my authority in writing.

Declaration

By signing this form, I declare that the information is true and correct. I acknowledge that I have read and understood the terms and conditions. I understand that Halaxy Pty Ltd (software) is used to store client data and information and their terms and conditions can be found on their website. I understand that I am personally liable for fees if a third-party funder I intended to use informs us/you they will not cover the service fees.

Signature*

Full Name of Parent / Caregiver / Guardian Completing this Form:*

First NameLast Name