!We've moved!

For our new client intake forms please follow: (it's easier and quicker!)

NSW Clients: https://fly2health.splose.com/public-form/6a7e4197-c02b-4ccd-aecb-0ad1aef10c6c

QLD Clients: https://fly2health.splose.com/public-form/9282f0f3-1ecb-42e9-b6ad-e70ef2d72a3e

SA Clients: https://fly2health.splose.com/public-form/51aa3b7f-5e9f-4ce0-bee9-3a5cdec9a02c

VIC/Tasmania Clients: https://fly2health.splose.com/public-form/049d2e7a-4653-4929-b0ef-6b949cf84d7f

WA Clients: https://fly2health.splose.com/public-form/2c8693ab-fee8-40a8-bd03-cefb3ee22f6a

PLEASE DON'T COMPLETE THIS FORM - CLICK ABOVE FOR NEW FORM

Location of Services *

If other, what location are you in? *

What is the appointment type requested? *

Please detail if specific reports/ services are required

How did you hear about us? *

Client Details

Client First Name *

Client Surname *

Client Date Of Birth *

Is the Client of Aboriginal or Torres Strait Islander origin?

NoYes, AboriginalYes, Torres Strait Islander

Street address *

City *

State *

Postcode *

Is the client the main contact for this referral and for service delivery? *

YesNo

This is the person we will contact about this application and during service delivery.

Client Email *

Client Phone *

Primary Contact

This is the person we will contact about this referral and during service delivery.

Primary Contact Name *

Relationship to Client *

Phone *

Email Address *

Alternative Contact

This is the person we should contact if we can’t get in touch with the client/ primary contact.

Alternative Contact Name *

Relationship to the client *

Phone *

Email Address *

Service Details

Please outline the number of sessions the client is to receive *GP Management Plans allow clients to receive 5 Medicare funded allied health appointments a year, please outline how many are to be utilised by which profession (e.g. 2 x Speech, 3 x Psychology).

Please outline the number of sessions the client is to receive *People of Aboriginal or Torres Strait Islander descent under Care Plans receive 10 Medicare funded allied health appointments a year, please outline how many are to be utilised by which profession (e.g. 5 x Speech, 2 x OT, 3 x Psychology).

Referring GP *

Referring GP Email *

NDIS Number *

NDIS Plan Start Date *

NDIS Plan End Date *

NDIS Management *

NDIS Plan ManagedNDIS Self ManagedNDIA Managed

If known, specify total allocated funds to Fly2Health

Support Coordinator (If different to the Client/ Representative) can be contacted on:

Support Coordinator Name

Support Coordinator Contact Number

Support Coordinator Email

Plan Manager Details

Plan Manager Name *

Plan Manager Contact Number *

Plan Manager Email *

Supporting Details & Documents

NDIS Plan OR Goals *

Browse

Aboriginal Health Medicare Care Plan *

Browse

GP Management Plan *

Browse

Previous Therapy and Assessment Reports

Browse

Diagnosis and/or Relevant Medical History *

What do you hope to achieve/ main therapy goals? *

Have you received therapy previously? *

YesNo

Please detail past therapy services *What therapy type did you receive (eg. Speech, OT, Physio) and where did you receive this therapy (Clinic name or contact details).

Payments

Fly2 Health Group will seek payment for their provision of support after the support has been delivered. We require payment by direct debit/EFT within 7 days. Please note that our cancellation policy is charged at 100% of the appointment fee for late cancellations and no-shows. We require 72 hours (3 business days) notice to reschedule/cancel appointments.

Email invoices will be sent to *If NDIS self managed, private or Medicare this will be your personal email, if NDIS plan managed this will be your NDIS Plan manager.

NOTE: All NDIS participants accessing our service require an NDIS Service Agreement.

This link will be sent to you automatically via email once our client services team book you in for an initial assessment appointment.

PLEASE DO NOT SUBMIT THIS FORM - SEE LINKS TO NEW FORM AT TOP OF PAGE

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