Therapy Pro Group Sessions

Participant details

Please let us know some information about the person who is going to participant in the group session.

Name*

Surname*

Street address

Town/City*

Postcode*

State*

Mobile phone number

Email address*

Date of birth*

How does the participant describe themselves?*

Male
Female
Nonbinary
Self-described

Please select what describes the participant best*

I am a current Therapy Pro client
I am a returning Therapy Pro client
I am a new Therapy Pro client

Please select which time and day suits you best

Usually we run group sessions at 4pm or 5pm on Wednesdays or Thursdays. Please provide any preference information below which may help planning our groups.

Select All
Tuesdays
Wednesdays
Thursdays
4pm
5pm

Please let us know which therapist you see at Therapy Pro

What is the main reason for attending a group session?*

Presenting difficulties*

Please tick the box if yes

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Does the participant have adequate understanding and use of words/language to engage in conversations?
Is the participant an independent communicator (does not rely on support worker/parent)?
Does the participant have basic literacy skills?
Does the participant have access to Zoom via a tablet/laptop/desktop?

Does the participant have difficulty with any of the following social skills:*

Please tick the box if yes

Does the participant have a disability or diagnosis that we should be aware of, that may impact the participant attending the groups sessions?

Is there anything that we should be aware of, for example, are there any behaviours of concern that may impact the participant attending the groups sessions? Please place any additional explanatory comments here that will help our facilitators place the participant in the most suitable group session.

Does the participant identify as:

Aboriginal and/or Torres Strait Islander
CALD

Does the person being referred require an interpreter?

Yes
No

Please tell us about yourself as the parent, guardian, carer or decision maker for the participant.

Decision maker name*

Decision maker surname*

Decision maker phone*

Decision maker email*

Decision maker relationship to client

Administrative details

So we can collect the required information for billing, please select which kind of referral this relates to.

Is the participant using NDIS funds to pay for the groups sessions?*

Yes, we're using NDIS funds
No, we'll pay another way

NDIS Participant Information

So we can set you up to use the funds from the participant's NDIS account, please let us know the following information.

What is the participant's NDIS number?*

Hidden

What is the Plan start date?

What is the Plan end date?

Please tell us who manages the participant's plan

NDIA
Plan
Self

If the participant is plan managed, please enter the Plan Management person's name or the company name.

If the participant has a Support Coordinator, please enter the Support Coordinator's name

How did you hear about us?

Submitting the form

By submitting this form you acknowledge that you are the participant's parent, guardian, carer or decision maker and you are providing consent for the participant to take part in Therapy Pro's group sessions. If you are unsure about something or would like to chat with someone about this referral, please call 1300 004 414 and our customer service team will be happy to support you.

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Group Sessions Questionnaire and Booking Form

Participant details

Please tell us about yourself as the parent, guardian, carer or decision maker for the participant.

Administrative details

NDIS Participant Information

Submitting the form

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