Participant intake form - Butterfly Effect Therapy

Personal Details

First Name*

Last Name*

Date Of Birth*

Gender*

Home Phone Number*

Mobile Phone Number*

Email address*

Language Spoken At Home*

Residential Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Communication & Support Needs

Preferred Option For Communication*

Phone

Email

Post

Do you require an interpreter?*

Yes

No

Is there a Guardianship and/or Administration order in place?*

Yes

No

For participants under the age of 18 years of age, under guardianship or in the care of family or caregivers, Please complete the Questions below:

Name of Parent/Guardian

First Name*

Last Name*

Relationship with participant*

Lives with participant*

Emergency Contact*

Residential Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Postal Address(if different from above)

same as above

Same as above

Postal Address(if different from above)

Street Address 1 Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone Number*

Mobile Phone Number*

Email address*

Disability/Medical Conditions*

Other Service Providers Currently using

How many service providers do you have?*

Service Provider 1

Full Name*

Mobile Phone Number*

Residential Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Frequency of use*

Service Provider 2

Full Name*

Mobile Phone Number*

Residential Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Frequency of use*

Service Provider 3

Full Name*

Mobile Phone Number*

Residential Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Frequency of use*

Health Care Information

Medicare Number*

Expiry Date*

Reference Number*

Private Health Provider*

Membership Number*

Reference Number*

Medical Doctor's Name*

Medical Doctor's Phone Number*

Address*

Street Address 1 Address Line 2 City State / Province / Region ZIP / Postal Code Country

Funding*

NDIS Managed*

Yes

No

A copy of the NDIS plan MUST be provided for NDIS managed participants.

NDIS Number*

NDIS Date*

Please choose:*

Self managed

Plan managed

Please provide details for invoices

First Name*

Last Name*

Email*

Phone Number*

Preferences

Preferred First Name*

Preferred Last Name*

Religious requirements*

Cultual requirements*

Communication device*

Physical assistance*

Other considerations*

Goals and aspirations

What do you want to achieve for yourself-life skills, physically,socially etc

Immediately*

In 6 months*

Next year*

Full Name*

Date*

Signature of Parent/Guardian*

Accepted file types: jpg, jpeg, png, Max. file size: 5 MB.

Ready to get started with Butterfly Effect Therapy?

Please complete form and submit

Personal Details

Communication & Support Needs

Name of Parent/Guardian

Postal Address(if different from above)

Other Service Providers Currently using

Service Provider 1

Service Provider 2

Service Provider 3

Health Care Information

Please provide details for invoices

Preferences

Goals and aspirations

What do you want to achieve for yourself-life skills, physically,socially etc