Participant Information Form

Welcome to Aspect Therapy!

Once we have received this completed form, we will be in contact within 3 weeks, to confirm that you are on our waitlist for the services you are requesting.

We will keep in touch with you via email or SMS so that our waitlists are up to date.

If you any questions regarding this form, please call us on: 1800 277 328 or email: customerservice@aspect.org.au

Participant Details - the person who will receive the supports

Participant First Name *

Participant Last Name *

Date of birth *

Gender *

FemaleMaleTheyOther

Please indicate preferred pronouns

If other, please indicate gender *

Email Address *

Mobile *

Participant Address *

Participant Address line 2

Participant City *

Participant State *

Participant Post Code *

How did you hear about Aspect? *

If other, please specify *

Participant Living Arrangements

Living Arrangements *

Who makes the decisions for this participant *

Languages spoken at home

Is an interpreter required *

YesNo

Do they identify as Aboriginal or Torres Strait Islander? *

YesNo

Are there any custody arrangements or parenting plans in place that we need to be aware of? *

YesNoI would prefer to discuss in person

If yes, please provide details. *

Enquirer Details

Who is completing this form *

I am the participantI am enquiring on behalf of the participant

First Name *

Last Name *

Mobile Number *

Email *

Relationship to the participant *

Please specify other *

Name of Organisation *

Street Address

Suburb

State

Postcode

Who is the best person to contact? *

ParticipantEnquirer (the person completing this form)Other (please specify below)

Contact's First Name *

Contact's last name *

Contact's relationship to participant *

Contact's email *

Contact's Mobile Number *Please provide mobile # as we send text messages to participants to shorten our waitlists

Reason For Referral

Tell us a little about you and your family, your child or the person who you are making the referral for. We'd love to know who lives in the home & what supports you have.

What are your goals for therapy? *

I would like to be waitlisted for *

Speech PathologyOccupational TherapySocial Work (not available in all areas)PsychologyBehaviour Support (Please ensure you have Improved Relationships Funding in your NDIS plan)Allied Health Assistant - in select areas

Early Childhood Supports (for children before attending primary school)

Individual Early Childhood Support sessionsBuilding Blocks - Parent trainingBuilding Tots - Transition to preschool program - select areas in NSW (for children aged 2-4 who are not yet enrolled in a preschool or childcare setting - program ends June 2024)

I'm interested in a Functional Capacity Assessment

YesNo

I'm interested in group therapy programs

YesNo

What type of therapy groups would you like to be waitlisted for? *

Parent Training GroupsAfter School GroupsSchool holiday groups

Please note: Aspect Therapy does not offer Functional Capacity Assessments for Supported Independent Living (SIL) or Specialist Disability Accommodation (SDA) purposes. Unfortunately, we are not able to provide this assessment via teletherapy at this time as we need to be able to meet the participant in person to appropriately complete the assessment.

Why are you seeking a Functional Capacity Assessment? *

Are you open to having a therapist come to your home/community to engage in discussion and complete observations? *

Yes No

Please Note: Our therapist are required to complete observations as a part of a Functional Capacity Assessment. We cannot complete the assessment at this time if clinical observations are not conducted.

Who has requested the Functional Capacity Assessment? *

Is the Functional Capacity Assessment to be used to support access to NDIS Funding? *

YesNo

What timeframe do you need the assessment completed by? *

Where would you like therapy to take place? (You can choose multiple) *

Please provide name and address of school

Please provide name and address of childcare

Please provide name and address of day program or other community site

Medical information

Does the participant have an Autism diagnosis (by a health professional or self-diagnosis)? *

YesNoAwaiting assessment/diagnosis

Are there any other co-occurring conditions/diagnosis (eg. Anxiety, ADHD)

Are there any medical conditions we need to be aware of?

Do you have any severe allergies or medical plans (eg. for epilepsy, asthma) that we need to be aware of *

YesNo

Medications

Paying for therapy

Information about our current Therapy Service fees is available HERE

How do you plan to pay for our services *

NDIS Details

NDIS Plan *

NDIS Managed: The provider claims money directly from my NDIS plan.Plan Managed: I have a plan manager who pays invoices for me.Self Managed: I receive and pay all the invoices for therapy myself.

Plan Manager Name

Plan Manager or Agency Email Address (for invoicing)

NDIS Number *

NDIS plan start date

NDIS Plan End Date

Behaviour Support

Are there any behaviours of concern that cause harm to the participant or to the people around them? (Please tick yes if you have requested behaviour support services above) *

YesNo

Please describe the behaviour you have concerns about *

How often do these behaviours happen?

Do you have "Improved Relationships" funding in your NDIS plan for Behaviour Support

YesNoI'm not sure

Have you previously had a Behaviour Support service?

YesNo

Keeping Everyone Safe

Do you have any pets/animals at home? *

YesNo

We kindly ask that you keep animals out of the therapy space whilst the sessions are in progress

Is there anyone in the home who has challenging behaviours *

YesNo

Does anyone in the home smoke or vape? *

YesNo

We kindly ask that you refrain from smoking/vaping when our staff are present in your home.

Is anyone in your home on Parole or Behaviour Bond *

YesNo

Is there a history of any form of substance abuse (including alcohol or illicit drug use) by anyone living in the home. *

YesNo

Other information about your supports

Have you ever accessed therapy supports before?

Are you currently receiving any therapy services?

Please outline the supports you are currently accessing:

Is there any other information you would like to share with us?

By ticking this, I confirm that all information supplied at the time of completion is accurate *

Thank you for your time in completing this form.

For information on any other services from Aspect please call 1800 ASPECT (1800 277 328)

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