Client Registration Form – Bright Start Therapy

Client Information

Name*

First Last

Date of Birth*

DD

MM

YYYY

Therapy Required

Occupational Therapy
Physiotherapy
Intensive Therapy

Does your child have a diagnosis? If yes please specify

Parent/Guardian Name*

First Last

NDIS funded?

Yes
No

NDIS number

NDIS Review Plan Date

Address*

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

Address different to Postal Address?

Postal Address (If different from above)

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

Email*

Phone*

Account Set Up Information

Name*

First Last

Relationship to Client*

Address*

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

Phone*

Parental/Guardian Letter of Consent

It is a legal requirement that we obtain permission from the client, or where a minor, the legal guardian, prior to starting intervention services with Occupational Therapy and Intensive Therapy at Bright Start Therapy. To provide consent please complete and sign this form.

Consent Form

Client's Full Name*

First Last

Parent/Guardian's Full Name*

First Last

I declare that I am the:*

Father
Mother
Legal Guardian of the above mentioned client

I hereby consent to (please tick applicable)*

Allow staff at Bright Start Therapy Pty Ltd to observe, assess, diagnose and treat The Client.
Allow staff at Bright Start Therapy Pty Ltd to discuss, consult, share written reports and collaboratively work with others (including carers, teachers, health professionals, etc) in delivering effective treatment for The Client.
Use photographs and videos as required as part of the program. These will not be used for any other purpose other than those explained by the therapist.
(OPTIONAL) Allow photos of The Client to be shared on Bright Start Therapy Facebook and Instagram pages for advertising and promotional use.
(OPTIONAL) Allow Bright Start Therapy Pty Ltd to use email as an efficient communication method.
(OPTIONAL) Allow Bright Start Therapy Pty Ltd to leave the school grounds with The Client for the purpose of a community visit. This will be discussed directly with you and the school prior to the date.

Client Agreement

I have acknowledged the information included in regards to the services offered by Bright Start Therapy PTY LTD. In reading this I understand that Bright Start Therapy provides both clinic and community based intervention for the individual and group therapy services. I also understand that by signing this agreement that my credit card will be debited as per the Bright Start Therapy cancellation policy outlined below.*

I have acknowledged and understand the information above.

Bright Start Therapy Client Registration Form

Client Information

Account Set Up Information

Parental/Guardian Letter of Consent

Consent Form

Client Agreement

Terms of Payment

About Us

Services

TheraSuit Intensive Programs & Physio

OT & Group Programs

Parents & Educators