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Client Registration Intake Form
HomeClient Registration Intake Form

    Child's Details

    Name:

    Age:

    Gender: Male/Female/Non-Binary/Other:

    Date of Birth:

    Country of Birth:

    Preferred Pronouns: She/HerHe/HimThem/They
    Ethnicity:

    Religious Beliefs: CatholicChristianIslamAnglicanHinduismSpiritualAgnosticAtheist

    Parent/Guardian 1

    Parent/Guardian's name:

    Date of Birth:

    Address:

    Suburb:

    Postcode:

    Parent's contact number

    Parent's email

    Parent/Guardian 2

    Parent/Guardian's name:

    Date of Birth:

    Address:

    Suburb:

    Postcode:

    Parent's contact number

    Parent's email

    Which Person is the best emergency contact:

    CONTACTS

    GP:

    Contact:

    Paediatrician:

    Contact:

    Other:

    Contact:

    School:

    Year:

    Contact:

    Medical/Allied Health Services who have been/are involved with your child:

    Diagnoses (Medical/Mental Health):

    Are you concerned about your child in any of the following areas:

    Academics

    Self Care Skills

    Social Relationships

    Emotionally

    Physical Skills

    Language Skills

    Behaviour Skills

    Inattention/Energy/Impulsivity

    Other:

    Terms of service

    Welcome to Deadly Descendants. Our terms of service and your rights and responsibilities as the client and/or parent in relation to information security, access and confidentiality as well as obligations regarding fees and cancellations are provided below.

    Information Security and Access


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

    1. It is subpoenaed by a court;

    2. Failure to disclose the information would place the patient or another person at risk of harm


    3. Your (Parent and/or Young Person where appropriate) prior approval has been obtained to:

      (a) Provide a written report to another professional or agency e.g. to a lawyer; or
      (b) Discuss the material with another person - e.g. a parent, educator or health professional

    
If you claim rebates from funding bodies, Deadly Descendants may be required to provide summary reports to referring doctors, specialists and/or agencies regarding the clients progress. Health research may be undertaken by Deadly Descendants, by funding bodies or by Deadly Descendants technology providers, which you consent to.

    Information Security and Access: In the course of treatment, personal information is collected to enable treatment. All notes taken in the course of treatment and all communications relating to treatment become a part of the clients clinical records. Clinical records are stored electronically in the patient file on Halaxy, which you consent to as a parent of or a client of Deadly Descendants. You have a general right access the patient record (subject to some exemptions which mainly relate to privacy, health, child consent or legal considerations) and a request must be made in writing. We are required to keep client personal information for 7 years after ceasing engagement with your treating counsellor/therapist and up to 25 years for a young person under the age of 18.



    APPOINTMENTS, FEES AND CANCELLATIONS

    Confirming appointments: We endeavour to confirm appointments via SMS or email. However, it remains your responsibility to be aware of the scheduled appointments.
    
Time and Punctuality: A consultation/session will usually run for a time of 50 minutes. If you are late, the consultation will finish at the scheduled time.
    
Cancellation Policy: Fees are payable at the end of the session via eftpos or via invoice which will need to be paid within 7 days if using an NDIS plan to pay for treatment. To cancel or postpone an appointment we require 48 hours notice. Cancellations less than 48 hours notice will incur a cancellation fee to the value of the appointment fee. This fee is not claimable through medicare or private health funds. This amount will be invoiced and sent out via post or email. In the unlikely event that this fee is not paid, we reserve the right to use a debt collection service. For NDIS clients, the consultation/session fee will be invoiced to your NDIS plan. If you have insufficient funds in your NDIS plan, you will be invoiced the fee personally.



    FEES AND PAYMENTS


    Consultation Fees: Fees are payable at the end of your appointment unless you are an NDIS client and your NDIS plan will be invoiced. Payments accepted include: cash, card or direct debit. NDIS clients are charged at the maximum rate within the latest NDIS Pricing Arrangements and Price Limits e.g. 15_606_0118_1_3 Capacity Building For Early Childhood Interventions - Counsellor $156.16, 15_043_0128_1_3 Assessment Recommendation, Therapy or Training - Counsellor $156.16. Please review our Fees Page on our website for more information about fees for consultations for fee-paying clients.

    Parent Signature


    Date:

    Youth Signature (For Youth over the age of 12)


    Date:

    Consent

    Dear Parent/Caregiver/Legal Guardian/Primary Carer



    Working with young people presents certain issues and legislation that counsellors/therapists must adhere to. The following clarifies where our role as a counsellor/therapist starts and ends. It also outlines our ethical and legal responsibilities with regards to working with young people. A  "young person" is defined as "someone under the age of 18 years old". A client-parent (or parents) is "the person who engages the counsellor/therapist to provide a therapeutic service for a young person". Whilst we do our best to communicate with the client-parent regarding the progress of the young person in counselling, we cannot disclose any personal information unless we gain verbal and written consent from the client, or if they are deemed too young to understand these terms, disclosure to the client-parent can occur.

    I give permission for (young person's name) to attend ongoing appointments without my presence. I understand that I will still be required to be available via phone/email for communication about their treatment and progress with treatment. I understand that part of their treatment plan may include recommendations from their counsellor/therapist that need to be implemented by me and/or the other client-parent in the home in order to progress their treatment.

    Young person's name:

    Parent Signature


    Date:

    Youth Signature (For Youth over the age of 12)


    Date:

    Consent To Sharing Information:
    Permission is given for Deadly Descendants to obtain and exchange appropriate written, electronic or verbal information with the following persons or agencies:
    ReferrerGPPediatricianSchoolPsychiatristOccupational TherapistPsychologistSpeech Therapist
    Other:

    Permission is given until I withdraw my permission in writing or for the following period from the date of this authority:
    In writing1 year
    Other:

    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 I am personally liable for fees if a third party funder I intended to use informs us/you that they will not cover the service fees. I understand that Halaxy Pty Ltd terms and conditions can be found on their website or I can request a copy.  

    Parent Name:

    Parent Signature


    Date:

    Young Person's Name:

    Youth Signature (For Youth over the age of 12)


    Date:

    Before you Submit your form please PRINT A COPY AS A PDF and email to: referrals@deadlydescendants.com.au

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