New Client Information Form | Total Health Choice

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Patient Details

Service*

Physiotherapy

Occupational Therapy

Exercise Physiologist

Speech Pathology

Who is this service for*

Funding Type*

Reason for Referral*

Desired Outcome*

Client Name*

First Last

Date of birth*

Email Address*

Phone*

Address*

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

Who to contact for appointments*

Child and School-Age Information

Who recommended or suggested seeking therapy?*

Please share any feedback or concerns that were raised.*

What are your goals for therapy?*

Improve independence

Prepare for school

Improve handwriting

Improve coordination

Reduce meltdowns

Increase confidence

Social Skills

Other

Other goal - please specify*

Therapy History

Has your child previously worked with any allied health professionals?*

Occupational Therapy

Physiotherapy

Speech Pathology

Psychology

Other

Other allied health professional - please specify*

If yes:*

What are the main concerns regarding communication?*

Do any family members have a history of speech or language difficulties? (Please tick)*

Speech/language difficulties

Stuttering

Learning difficulties

Hearing impairment

ADHD

Autism Spectrum Disorder

Dyslexia

Cleft Palate

Other

Other family history - please specify*

Any difficulty with any of the following? (Please tick all that apply)*

Attention and concentration

Understanding and expressing feelings/emotions

Understanding language

Reading/written expression

Stuttering

Producing speech sounds/producing words/constructing spoken sentences

Expressing wants/needs

Making friends/taking turns/engaging in conversation

Other

Other difficulty - please specify*

Are you seeking:*

NDIS Information

NDIS Goals

Drop files here or

Accepted file types: png, docx, pdf, jpg, jpeg, Max. file size: 20 MB, Max. files: 10.

Supported formats include PDF, DOCX, JPG, JPEG and PNG, up to a total combined file size of 20MB (maximum 10 files).

Is a Report Required?*

What Type of Report?*

Diagnosis*

Fund management*

Plan Manager*

Plan Manager Email*

NDIS number*

Plan start date*

Plan end date*

Do NDIS funding periods apply?

NDIS Funding Breakdown – Please specify funding amount per period

Allocated Hours/Budget for Support*

How much funding is available for support

Do you have a Support Coordinator or LAC?*

Support Coordinator/LAC Name*

Business Name*

Support Coordinator/LAC Contact Number*

Support Coordinator/LAC Email*

Interpreter required*

Yes

If yes, which language?*

OH&S Risk Assessment

OH&S Risk Assessment*

Self harm or harming others

Property destruction

Verbal aggression

Physical aggression

Drug or alcohol use

Inappropriate behaviours

Other behaviours of concern (Hoarding or Hygiene Concerns)

Other

Other OH&S risk - please specify*

SAH Funded Information

Who is your Aged Care Provider? (Company Name)*

Where to send invoices?*

Invoice Email Address*

Do you have a Care Coordinator?*

Care Coordinator's Name*

Care Coordinator Phone Number*

Care Coordinator Email Address*

Private Paying Information

Invoice Preferences*

Invoices sent at the end of each calendar month

Invoices sent after every appointment

TAC Claim Details

TAC Claim Number*

Date of Motor Vehicle Accident*

Claim Status*

Is the claim currently accepted, pending, or under review?

Case Manager Name

Contact Details*

Accident and Injury

Description of the Accident*

A brief overview of what happened

Injury(s) Sustained*

Please list all injuries related to the accident

Hospital Attendance*

Yes

If yes, which hospital and on what date?

Pre-existing Conditions*

Any prior injuries, surgeries, or conditions in the same areas affected by the accident.

Employment and Functional Impact

Pre-injury Occupation

What was your job and employment status before the accident?

Current Work Capacity

Do you have an active Certificate of Capacity from your doctor?

Yes

Functional Limitations

Please list 2–3 daily activities you are currently struggling with due to the accident.

Financial Consent and Acknowledgment

Information Sharing Consent*

I consent Total Health Choice sharing my information.

Explicit permission for Total Health Choice to share medical reports, treatment plans, and notes with the TAC, your GP, and other relevant medical professionals.

Financial Liability*

I agree to financial liability if TAC rejects the claim, denies a treatment plan or ceases funding.

Acknowledgment by you stating that if the TAC rejects your claim, denies a treatment plan or ceases funding, the client is personally responsible for covering the cost of the consultations/appointments.

Emergency Contact

Full name

Relationship

Phone number

Referrer

Who is submitting this form?*

Support/Care Coordinator

Self

Family Member

Other

Other - please specify*

Referrer Name*

Referrer Phone*

Referrer Email*

How did you hear about us?*

Other:

Credit Card Requirements

Please provide a valid payment method. Card details will be handled securely through Gravity Forms Stripe.

Payment Method Acknowledgement*

Please acknowledge

I acknowledge that a valid payment method is required and authorise Total Health Choice to securely store or process the payment method in accordance with its payment terms.

Please note that our policy for private/self-managed clients is to keep a credit card on file for payment of services.

We securely store credit card details (via Square) for payment of services.

All invoices are sent directly to you for payment, If payment is overdue by more than 30 days, we will be in touch to collect payment.

Details can be provided by phone on 1800 847 847 or via email at info@totalhealthchoice.com.au.

Add payment method*

American Express

Discover

MasterCard

Visa

Supported Credit Cards: American Express, Discover, MasterCard, Visa

Card Number

Expiration Date Month Year

Security Code Cardholder Name

Securely enter card details. A Gravity Forms Stripe feed must be configured after import to store or process the payment method.

Would you like to opt in for direct debit, where your card will be charged after each session?*

Yes

I authorise Total Health Choice to securely store my credit card details and automatically charge my card on file following the completion of each appointment. I understand and agree that a processing fee of 1.95% + $0.30 will be applied to each transaction.

I agree to the privacy policy.

Policies and Consent

I reviewed and I accept

Upon submitting the form, your personal details will be sent securely to Total Health Choice. Please review and accept the privacy policy of Total Health Choice.

Consent*

Please consent

I have obtained consent from the client, NOK, or guardian, to provide the client's personal information to Total Health Choice for further assessment.

File upload

Drop files here or

Accepted file types: pdf, Max. file size: 20 MB, Max. files: 10.

Supported formats include PDF only, up to a total combined file size of 20MB (maximum 10 files).

Note:

Once you’ve completed the referral, please click submit.

If you need to provide further information, please get in touch with us on 1800 847 847 or info@totalhealthchoice.com.au.