Berdy Occupational Therapy Intake Form

Client name*

First NameLast Name

Client's usual address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Client's date of birth*

Date

Client Phone Number*

Client Email Address*

Gender and preferred pronouns*

GenderPreferred pronouns

Is the client aged 18-years or older?*

YesNoNo, and will be accompanied by a parent/guardian

For clients aged under 18-years, please provide contact details for primary parent/guardian below.

Contact person - Parent or Guardian

Parent phone number

Parent email address

Client's primary occupation / life role (eg. student, mother, grandmother, etc)*

Reason for referral to OT (what are the client's specific needs or goals?)*

Key concerns or issues would the client like to work on with the OT?*

Medical conditions/diagnoses (including mental health, alerts and allergies)*

Medication and dosage (if known)*

Current (or past) medical, allied health, and/or other supports*

Sensory / accessibility needs (if any)*

Client | At the moment, how would you rate your overall health and wellbeing?*

1 is Extremely poor, 5 is Excellent

Client | What do you think has contributed to this?*

Has this changed over the last 12-months?

Previous reports/assessments/letters (upload or email hannah@berdyoccupationaltherapy.com.au)

Billing and Payment Options

Please select the method you will use for payment*

Medicare | Please provide your card number and expiry date (if using for payment):

Medicare Card NumberExpiry date

If using NDIS funding, please specify arrangement for invoicing:

Self managedPlan managedNDIA managed - Services not available at Berdy Occupational Therapy

NDIS | Plan Manager (organisation name, contact email)

OrganisationContact email

NDIS | Participant number and plan dates

NDIS Participant NumberPlan dates

NDIS participant number

NDIS | Support Coordinator

Name / OrganisationContact email

NDIS Plan (upload or email hannah@berdyoccupationaltherapy.com.au)

Consent for Occupational Therapy Services

Occupational Therapy Service - Assessment and Therapy Consent

This Consent for Occupational Therapy Services form is designed to protect your rights and ensure that you receive optimal care. Please read and complete this form thoroughly before beginning your Occupational Therapy services with Berdy Occupational Therapy. Your signature below indicates your understanding and acceptance of the terms and conditions outlined.

"Occupational therapy assessment" as used here describes the following professional services:

Occupational therapy assessment is the initial phase of the therapeutic process, where an occupational therapist evaluates a client's physical, cognitive, emotional, and functional abilities. This assessment helps identify areas of difficulty, goals, and appropriate interventions.

"Occupational Therapy Treatment (Intervention)" as used here describes the following professional services:

Occupational therapy treatment, often referred to as intervention, encompasses the treatment and strategies used by occupational therapists to help clients achieve their therapeutic goals. It may include various activities, exercises, and techniques tailored to the client's needs.

Occupational Therapist (OT) as used here describes a licensed healthcare professional who specialises in assisting individuals in achieving and maintaining independence in their daily activities (occupations). They assess, plan, and implement interventions to improve a client's functional abilities.

Occupational Therapy Service – Therapy and Assessment

As part of providing an occupational therapy service to you Berdy Occupational Therapy needs to collect and record personal information from you or your child that is relevant to your situation, such as your name, contact information, medical history and other relevant information as part of providing occupational therapy services to you. This collection of personal information will be a necessary part of the occupational therapy assessment and intervention that is conducted.

Purpose of collecting and holding information

Your personal information is gathered as part of your assessment and treatment is kept securely and, in the interests of your privacy, used only by your occupational therapist and the authorised personnel of the practice (as necessary). Your personal information is retained in order to document what happens during sessions and enables the occupational therapist to provide a relevant and informed occupational therapy service to you.

Consequence of not providing personal information

If you do not wish for your personal information to be collected in a way anticipated by this form Berdy Occupational Therapy may not be in a position to provide the occupational therapy service to you. You may request to be anonymous or to use a pseudonym, unless it is impracticable for Berdy Occupational Therapy to deal with you or if Berdy Occupational Therapy is required or authorised by law to deal with identified individuals. In most cases it will not be possible for you to be anonymous or to use a pseudonym, however if Berdy Occupational Therapy agrees to you being anonymous or using a pseudonym, you must pay consultation fees at the time of the appointment.

Access to client information

At any stage you are entitled to access your personal information kept on file, subject to exceptions in the relevant legislation. The occupational therapist may discuss with you different possible forms of access at your request.

Disclosure of personal information

All personal information gathered by the occupational therapist during the provision of the occupational therapy service will remain confidential except when:

It is subpoenaed by a Court;

Or failure to disclose the information would in the reasonable belief of Berdy Occupational Therapy place you or another person at serious risk to life, health or safety;

Or your prior approval has been obtained (verbal permission) to:

Provide a written report to another professional or agency. e.g., a GP or a lawyer; or
Discuss the material with another person, eg. a parent, employer or health provider; or
Disclose the information in another way; or you would reasonably expect your personal information to be disclosed to another professional or agency (e.g. your GP) and disclosure of your personal information to that third party is for a purpose which is directly related to the primary purpose for which your personal information was collected;

Or disclosure is otherwise required or authorised by law.

Your personal information is not disclosed to overseas recipients, unless you consent or such disclosure is otherwise required by law. Your personal information will not be used, sold, rented or disclosed for any other purpose.

Client Safety

Parents or guardians of a client with a medical condition who may require emergency management or medication during their session (asthma inhaler, Epipen, seizure assistance etc) are required to stay within the building at all times during their child's session unless otherwise discussed. No food is to be eaten in the waiting room.

For clients aged 16 and under, a parent or guardian should be available at all times during the scheduled session. In the event that the parent/guardian must leave the rooms, they are required to return fifteen minutes before the end of the session. No children under the age of 12 are to be left unattended in the waiting room. There must be a parent/guardian to actively supervise at all times.

Consent by non-client parent (child clients)

If it is made known to us that one parent does not consent to their child accessing allied health services or if it becomes known to us during treatment that a non-client parent does not consent, then treatment will cease. We can instead provide services to the consenting parent to help support their child.

Expectations of interactions and attendance

At Berdy Occupational Therapy, we have the following expectations of clients and anyone attending our space with clients:

Respectful communication with staff and other clients, including face-to-face, over the phone, email and other.
When at Berdy Occupational Therapy: Behaviour not tolerated that others in the space may find offensive or discriminatory.
No taking photos, videos or voice recordings when in the building or in appointments, unless discussed and approved by practitioner.
We have a no-tolerance policy for bullying or disrespectful behaviour towards our staff which will result in a ceasing of services.

Limitations of Supports

At Berdy Occupational Therapy, we are a small privately owned and operated business. By signing our consent form you acknowledge that:

When staff leave, reduce times or take on other tasks to differ their practice, we may not be able to provide you with ongoing support.
We work with best-fit clients who we are able to support within our scope of practice, and may not be able to provide you services despite signing consent or being on a waiting list.
Due to our Codes of Ethics, if there is a conflict of interest or dual relationship, we will cancel appointments with minimal notice despite you having been on a waiting list.

Client Agreement

By signing below, you acknowledge that you have read, understood, and agree to the terms and conditions outlined in this Consent for Occupational Therapy Services form. This agreement ensures a positive and effective experience at Berdy Occupational Therapy.

Please tick if you have read, understood and consent to consent form*

Yes

If you consent to the above conditions, please sign your Signature*

Berdy Occupational Therapy Fees

NDIS Occupational Therapy: $193.99 per hour (in line with the NDIS Price Guide)

Private (self-funded) Occupational Therapy: $190 per hour

Fees are charged for:

Direct appointments, face-to-face meetings or appointments, as well as telehealth appointments or phone appointments One hour appointments inlcude 45 minutes direct time with the client and 15 minutes note taking without the client at the end, pro rata for all other times (1.5, 2 hours, etc).
Prior to accepting the referral: Discussions with your or your/child's support coordinator in order to clarify the purpose of the referral. Planning and preparation prior to your initial appointment if necessary.
All phone and email communication, especially for extended emails. To avoid these charges please bring queries to sessions rather than emailing.
Writing of file notes and writing assessment reports for you and the NDIS.
NDIS review reports will be completed when requested by the client, parent, support coordinator, or NDIS (LAC, etc) and will be charged up to 3 hours.
Travel expenses: As per NDIS guidelines travel is billed as practitioner time as well as an additional fee of 90c for every km travelled. The 90c per km is to ensure staff are being compensated for their costs when travelling. Consent to fees includes consent for both aspects of the travel charge for all requested off-site appointments.

NDIS CLIENTS

You will immediately notify Berdy Occupational Therapy:

If the participant’s NDIS Plan is replaced by a new plan or the participant stops being a participant in the NDIS; and
If self-managed or plan-managed, you will ensure sufficient funds are available to pay for sessions and, if not, you will take responsibility for the payment of outstanding fees.

Please tick if you have read, understood and consent to all fees*

Yes

Please sign if you consent to the above fees*

Occupational Therapy Service - Cancellation Policy

Fees for Cancellation of Appointments
No fees if appointments cancelled more than 48 hours prior. For Monday and Tuesday appointments cancellations need to be made by 12pm the Friday prior.

If cancelled or no attendance within 48 hours full fees will be charged.

Appointment reminders may be sent via text message or email prior to appointment as a courtesy. Not receiving them is not a reason for non-attendance. If a cancellation fee applies an invoice will be sent via email and must be paid before future appointments are able to be rebooked. If consecutive non-attendance or late cancellations occur, we will require you to pre pay fees before future sessions or sessions may be cancelled.

Please tick if you have read, understood and consent to the cancellation policy.*

Yes

Please sign if you consent to the cancellation policy*

Intake form - New occupational therapy client