Embrace Neurodivergence Intake Form

NDIS Invoices will be created and you will gain access to Embrace Neurodivergene within 2 - 3 days, allowing time for the details to be processed. If you have any questions please reach out to [email protected]

First Name *

Last Name *

Address

Street Address *

City/Town *

State/Province *

Postcode *

Email *

Phone *

Date of birth *

Pronouns

Communication Preferences

Appointment reminders are sent two days before any appointment or Zoom calls

How would you prefer to receive appointment/zoom call reminders *

SMS

SMS & Email

None

Add my email to the Better Being Me communication list for updates on events and latest information *

Yes

NDIS Details

details of the person with the NDIS plan

Embrace Neurodivergence to Invoice as: Select the best option for your plan.

Parent/Carer Training (CB):15_038_0117_1_3

Increased Social and Community (CB): 09_008_0116_6_3

Social & Community (Core) - 04_210_0125_6_1

Are you an NDIS Participant? If no, please continue to the next section. *

Yes

NDIS Participant Name: (child's name if you are claiming under parent training)

NDIS Participant Number

Fund Management

Plan Manager Name

Plan Manager Email

Discount Code

Privacy and Confidentiality

Better Being Me needs to collect information about you/your child for the primary purpose of providing a quality service to you/your child. In order to thoroughly assess, diagnose and provide therapy, we need to collect some personal information from you (or about your child). If you do not provide this information; we may be unable to treat you/your child. This information will also be used for: a) the administrative purpose of running the practice; b) billing either directly or through an insurer or compensation agency; c) use within the practice if passing your case to another clinician within the practice for your/your child’s ongoing management; d) where applicable, notifying the relevant statutory service/s if there is a real or suspected threat to you/your child's safety and wellbeing, that of a third party or the public; e) disclosure of information to your/your child’s doctors, education, other health professionals to facilitate communication and best possible care for you/your child; and f) in the case of insurance or compensation claim it may be necessary to disclose and/or collect information that affects your return to work. Therapy sessions will not be video or audio recorded with the explicit, written, advance consent from both the therapist and the client/nominee. We do not disclose your personal information to overseas recipients or for marketing purposes.

I am aware that I can request and read the Privacy Policy by contacting [email protected]. *

Yes

I acknowledge Better Being Me is a mandatory reporter and in accordance with our legal duty of care, will contact the appropriate services if your or another person’s safety and wellbeing is at real or perceived risk. *

Yes

I confirm I have provided true and correct information on this form *

Yes

Date *

Signature *

Clear