Adult Client Intake Form

Your Details

Your Name(Required)

First Last

Your Date of Birth(Required)

Your Gender(Required)

Mobile Number(Required)

Home Phone Number

Email Address(Required)

Address(Required)

Street Address Address Line 2 Suburb State Postcode

Presenting Issues

Does you have a formal diagnosis? If so, please list (eg. Autism, ADHD, Depression etc)

Briefly explain your reason for seeking service at Okey Dokey(Required)

Payment Method

Please select your preferred payment option(Required)

I will pay on the day privately

I will pay on the day and get a rebate from Medicare for part of the cost (I have a plan from the doctor)

NDIS Self Managed: I will pay on the day and get reimbursed by NDIS

NDIS Plan Managed: Please send invoices to my Plan Manager for payment

Your NDIS number

NDIS Plan Manager Details

Plan Manager Company

Plan Manager Contact Person

Plan Manager Phone for invoicing

Plan Manager Email for invoicing

Medicare Details

If you have selected to use a Medicare plan to access a rebate for part-reimbursement of session costs at Okey Dokey, please complete the following details and attach a copy of your plan below. Claimant details refer to the adult claiming on the child’s behalf and are required in order to process any Medicare claims.

Your Medicare Card Number

Your IRN (Individual Reference Number)

Additional Information

Upload Files

Drop files here or

Max. file size: 256 MB.

Please attach any additional information relevant to your therapy at Okey Dokey (e.g. reports, Medicare referrals, NDIS information, etc) to be stored securely on file.

Agreement

Your Signature(Required)

I am signing to confirm that everything submitted in this form is true and accurate.

Adult Intake Form