Client name
Date of birth
Address
Phone
Email
Emergency contact
Emergency contact number
Relationship to client
Who shall we contact to book the initial assessment?
Name
Case manager name
Organisation and role
Case manager phone
Case manager email
Main reason for referral to Dietitian or Psychologist:
Which office/department/organisation is responsible for payment of services?:
Organisation
Claim number
Approval number (if relevant)
Invoice to be sent to email
The initial evaluation enables the clinician to conduct a comprehensive assessment, engage in goal discussions, and establish a future plan. Following the initial assessment, a report outlining suggested interventions and associated costs will be sent to you for review. We will not proceed with any additional services until we receive your written approval, which you can provide by signing the final page of the report.
Initial Assessment and Report: DietitianPsychologist
Where should the report be sent to? Email
Do you require a formal quote on letterhead before proceeding with the initial appointment? YesNo
YesNo
What is the name of the GP?
Practice name
If so, do they also have a care plan (Chronic Disease Management Plan, Mental Heatlh Care Plan or Eating Disorder Plan)
Does this client have an NDIS Plan? YesNo
Any additional information to assist with proceeding with assessment and /or treatment? Any safety issues present?
*Service Fee as of July 2024 - subject to change as required:
NOTE- these fees are provided for informaiton purposees only. Subsequent sessions following the initial assessment will be detailed and costed in the initial report, and further services will not be provided until signed approval received.
Clinic Based Initial Assessment (includes report): Dietitian $405 | Psychology
Position
Date
