Registration Form- Sydney

New Client Registration Form

CLIENT DETAILS (child's details)

First Name *

Last Name *

Preferred Name

Date of Birth *

Child's sex

MaleFemaleIntersexPrefer not to say

Leapfrog is LGBTQIA+ inclusive, and want to respect the choices of both you and your child. If your child's gender identity or pronouns differ from those commonly used with their birth sex, please indicate their preferred identity/pronouns below:

English is a Second Language *

YesNo

Primary Language *

If possible, would you like us to engage interpretation services to assist with the therapeutic relationship?

YesNo

Ethnicity

Are you located in Melbourne or Sydney? *

MelbourneSydney

CONTACT DETAILS

Emergency contact name: *

Mobile Phone *

Email *

Home address:

Street

Suburb

State

Postcode

Does your child live at this address with both parents together? *

YesNo

Are there any court orders in place?

YesNo

We require all children under 14 years to be collected from the clinic by an authorised adult. If your child is 14 years or older, do you consent to them leaving the clinic unaccompanied?

YesNo

Please provide any additional information regarding your child's home life you feel is relevant. i.e., detail of court orders, limited contact with a parent etc. Please also note that if your family circumstances change throughout your time with Leapfrog, it is your responsibility to notify the team here so that we can continue to deliver the highest standard of service to your child.

SEPARATED PARENTS/FAMILIES POLICY

Our Requirements and Expectations

1. It is our expectation that separated parents work together respectfully and cooperatively regarding the care of their child.  

2. It is the parents’ obligation to provide us a copy of any relevant legal documents or court order prior to therapy commencement. 

3. Either parent or legal guardian can:

schedule an appointment with their child
be present at their appointment
and/or request a copy of the child’s reports or treatment notes

UNLESS there is a court order restricting their involvement in their child’s care. If this is the case, please ensure you provide these court orders at your first visit to the clinic.

4. If an appointment is made by one parent, it is the responsibility of this parent to inform the other parent, invite them to attend, and/or provide feedback to them.

5. Assessment reports will be sent to the parent(s) who attended the assessment appointment as standard. If only one parent attends, it is their responsibility to forward the report to the other parent. 

6. We do not have the capacity to provide separate intakes or feedback appointments for each parent but welcome both parents to attend appointments and will provide copies of correspondence to each parent if specifically requested.

7. Leapfrog Therapy will not accept part payment of therapy invoices.  If there is legal agreement that requires one parent to pay all or part of the treatment costs, one parent will need to provide credit card details and seek reimbursement directly from the other parent.

8. Where there is significant conflict between separated parents, we reserve the right to request court orders, obtain signed consent from both parents prior to any service provision, or limit our services until the dispute has been resolved.  If necessary, we may discharge a family from services if the conflict is disruptive to the clinic or impedes the care of the child.

9. We do not take referrals where the purpose of the assessment is to generate information for legal decision making around custody issues of parental separation.

Signing this document acknowledges you have read the above policy and agree to abide by this agreement: *

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EDUCATIONAL INFO

Our therapists work closely with teachers. The more contact details we have for them the easier this is!

My child's school/ Preschool/daycare (NOTE if yours is not listed, please let us know their school below)

Name of school/kindergarten/daycare

If kinder/daycare, what days of the week do they attend?

Teacher Name and Year Level

Is your child's school a specialist school?

YesNo

SUPPORT NEEDS

Services required *

I know the specific service my child requires:

Describe any concerns/growth areas regarding your child's development: *

Please provide additional information regarding your child's diagnosis. If your child has been identified with Autism, please describe their level. If your child has a diagnosis not listed above, please provide more information.

Leapfrog is committed to working collaboratively with your other services to best support your child. Please indicate any other Allied Health professions your child currently engages with: *

For any services you selected above, please indicate here the frequency of your child's engagement with those services (i.e. weekly. fortnightly, monthly, consultative, etc.):

Does your child currently engage in ABA therapy? If yes, how often? *

To your knowledge, has your child ever displayed 'at-risk' emotional wellbeing behaviours to self/others (e.g. expressed feelings of low mood/hopelessness/self-harm)? *

YesNo

To your knowledge, has your child ever demonstrated any challenging behaviours (e.g. emotional meltdowns, physical aggression, tendency to abscond) which might impact their ability to engage with O.T. or Speech Therapy? *

YesNo

REFERRAL AREAS

FUNDING

Does your child have NDIS funding? *

Our fee schedule can be found here: CLICK HERE

I confirm that I have read the attached fee schedule and are willing to proceed with registration based on this. *

SIGNATURE

Patient/ Guardian Signature

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