Registration of Interest Form
Participant Details:
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
example@example.com
Guardians Name (if applicable)
First Name
Last Name
Guardians Address (if applicable)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Guardians E-mail
example@example.com
Guardians Phone Number
Emergency contact
*
First Name
Last Name
Emergency Phone Number
*
How do you prefer to be contacted?
*
Phone
Email
Guardians phone
Guardians email
Either my phone or email
Either my guardians phone or email
Do you have NDIS funding?
*
Yes
No
Unsure
Are you?
*
Self managed
Plan managed
NDIS managed
Self funded
Other
NDIS Reference Number
Is respite included in your NDIS plan?
*
Yes
No
Unsure
N/A
Tell us a little about your story- what leads you here?:
*
What are your support/therapy needs?:
*
Drs/specialists information:
*
Full Name
Occupation
Contact Number
Specific purpose
1
2
3
4
5
Thank you for taking the time to fill out this form, we look forward to connecting with you! Mia will be in contact with you within 2 business days to discuss your needs in the format you have preferred. Your confidentiality is important to us, your information will not be shared unless by matter of law. If both parties decide to proceed with support, under the NDIS guidelines, we will send out an agreement for you to peruse and sign. We cannot begin sessions under the NDIS without this step. As per the nature of Support Work and Somatic Therapy, informed consent to touch appropriately is required prior to beginning our sessions, with a regular checking in for continued consent-your comfort is our concern. You can choose to change your mind about your support/therapy needs at any time, in the instance of late notice, fees may be incurred as per NDIS guidelines and our signed agreement, at the discretion of That Happy Place. Please share any other details, questions or concerns you feel would be helpful here.
The information I have offered is true and correct to the best of my knowledge -Signature
Date
-
Month
-
Day
Year
Date
Please verify that you are human
*
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Should be Empty: