New Client Form

These supports will be provided by our therapists at the Head 2 Toe clinic (unless otherwise specified) for the duration of this service agreement. Please note, the premises entry and exit points are under security surveillance.

I consent to my treating therapist being able to release and receive pertinent information from other relevant people (professionals, family, care givers) to assist in providing a coordinated therapy plan / intervention.

I understand the fees associated with the services I will receive are: $175.00 per one hour session for initial consultations, ongoing treatment and initial assessments (excluding psychometric and diagnostic testing); $131.25 per 45 minute sessions and $175.00 for report writing (where applicable). 

The above rates are for Private Paying Clients. NDIS rates are: $185.00 per one hour session for initial assessments (excluding psychometric and diagnostic testing) and ongoing treatment sessions ($195 for psychology); $150.00 per 45 minute session and $185.00 minimum ($195 for psychology) for report writing (where applicable).

Any additional reports, letters, third party consultation charges shall be first discussed and charged accordingly (where applicable).

I understand that:

• I am responsible for funding these services
• Payments will be made on the day of consultation
• A cancellation fee will be charged if less than 2 business days’ notice is provided. If notification of cancellation is received within this notice period, a $100.00 missed appointment fee will be applied.
• In instances where you or your child are sick, a medical certificate may be requested.
• Where a client does not attend an appointment without any notification the full consultation fee will be charged.
• Credit card details will be collected of any new client joining Head 2 Toe. No charges or utilisation of credit card information will take place without first receiving consent from the client.

• Listen to your feedback and resolve problems quickly and fairly
• Issue regular invoices and/or statements of supports delivered
• Treat you with courtesy and respect
• Communicate openly and honestly
• Ensure continuity of support in the event of staff unavailability (e.g. due to sick leave) or transition. If this takes place, clients will be informed with as much notice as possible to mitigate the impact of therapeutic disruption.
• Therapist unavailability will be avoided as much as possible. In the event where it is unavoidable, notice will be provided to clients via phone with as much notice as possible. Where available, another therapist might be appointed as deemed appropriate by the centre.
• Throughout the period of this service agreement, is it the responsibility of Head 2 Toe to ensure that support services are implemented and customised sufficiently to suit your child and the family’s requirements/ preferences. Discussions with clinicians directly, at the outset of treatment/ intervention should be held to ensure that all needs are communicated and are being met. These needs will be recorded with the support plan.
• Information about advocacy services can be found at the end of this document. If you require assistance with contacting these services, please don’t hesitate to ask our receptionist.

In the case of any accident or incident that occurs while on Head 2 Toe property or with Head 2 Toe employees, a detailed incident report form will be completed within 48 hours.

The report will include:

• A description of the nature and extent of the incident
• The name and contact details of all those involved, including any witnesses to the incident
• The action taken
• The date and signature of the person making the report
• Any on-going or follow up action

• You are required to follow any staff requests in relation to health, safety and safe lifting practices.
• Any photographs or videos you take of service/therapy sessions are for private use only. You agree not to share these          on social media or in any other way.
• You are required to attend your appointment on time. Should there be delay in attending an appointment, notice must be given via phone to the administration team of Head 2 Toe.
• Payment of sessions should be made upon arrival at Head 2 Toe. Invoices will be provided for all sessions conducted.
• Head 2 Toe reserves the right to pause clinical services due to accounts having outstanding/ unpaid invoices.
• All children must be escorted to by their parent or a staff member to the toilet
• If you or your child are responsible for considerable damage of Head 2 Toe property, the onus and cost of repairing    damage falls upon you. 

Any changes to this service agreement must be received in writing at info@head2toefamilyhealth.com.au

Supports may be withdrawn or concluded for the following reasons:

1.    Clinical goals being achieved and monitoring of the client’s well-being has concluded i.e. client has reached the natural therapeutic “stopping point”. 

2.    Three (3) consecutive occasions wherein appointments are cancelled within 48 hours of the scheduled appointment.

3.    Three (3) consecutive occasions wherein appointments are not attended without prior warning of the appointment requiring cancelation.

If you have any problems, concerns, wish to provide feedback or make a complaint, please contact our office manager on 02 8894 1013 or alternatively you can send her an email, info@head2toefamilyhealth.com.au

For NDIS participants, you can contact the NDIA on 1800 800 110 or visit the NDIS website if you feel your concern has not been addressed.

In Accordance with taxation law:

A supply of supports under this Service Agreement is a supply of one or more reasonable and necessary supports specified in the statement of supports included, under subsection 33(2) of the National Disability Insurance Scheme Act 2013 (NDIS Act), in the participant’s NDIS Plan currently in effect under section 37 of the NDIS Act.

We are committed to protecting the privacy of patient information and to handling your personal information in a responsible manner in accordance with the Privacy Act 1988 (Cth), the Privacy Amendment (Enhancing Privacy Protection) Act 2012, the Australian Privacy Principles and relevant State and Territory privacy legislation (referred to as privacy legislation).

This Privacy Policy explains how we collect, use and disclose your personal information, how you may access that information and how you may seek the correction of any information. It also explains how you may make a complaint about a breach of privacy legislation.

This Privacy Policy is current from the 15th of October 2018 and is reviewed periodically. From time to time we may make changes to our policy, processes and systems in relation to how we handle your personal information. We will update this Privacy Policy to reflect any changes. Those changes will be available on our website and in the practice.

Please note these premises are under security surveillance.

We collect information that is necessary and relevant to provide you with allied health care and treatment and manage our practice. This information may include your name, address, date of birth, gender, health information, family history, credit card and direct debit details and contact details. This information may be stored on our computer medical records system and/or in handwritten medical records.

Wherever practicable we will only collect information from you personally. However, we may also need to collect information from other sources such as paediatricians and other health care providers, and the Myhealth record system.

We collect information in various ways, such as over the phone, or in writing, in person in our centre or over the internet if you transact with us online. This information may be collected by clinical and non-clinical staff.

In emergency situations we may also need to collect information from your relatives or friends.

We may be required by law to retain clinical records for certain periods of time depending on your age at the time we provide services.

We will treat your personal information as strictly private and confidential. We will only use or disclose it for purposes directly related to your care and treatment, or in ways that you would reasonably expect that we may use it for your ongoing care and treatment.

There are circumstances where we may be permitted or required by law to disclose your personal information to third parties. For example, to Medicare, Police, insurers, solicitors, government regulatory bodies, tribunals, courts of law, hospitals, debt collection agents, the electronic transfer of prescriptions service or to the Myhealth record system.

We may disclose information about you to outside contractors to carry out activities on our behalf such as an IT service provider, solicitor or debt collection agent. As per NDIS procedures, we are required to provide client files for auditing purposes. You may also be required to participate in interviews. If you do not wish to have your file available for this, you may opt out in writing at the end of this document. We impose security and confidentiality requirements on how they handle your personal information. Outside contractors are required not to use information about you for any purpose except for those activities we have asked them to perform.

We will take reasonable steps to ensure that your personal information is accurate, complete, up to date and relevant. For this purpose our staff may ask you to confirm that your contact details are correct when you attend a consultation. We request that you let us know if any of the information we hold about you is incorrect or out of date.

Personal information that we hold is protected by:

● securing our premises;

● placing passwords and varying access levels on databases to limit access and protect electronic information from unauthorised interference, access, modification and disclosure; and

● providing locked cabinets and rooms for the storage of physical records.

If you believe that the information we have about you is not accurate, complete or up to date, we ask that you contact us in writing (see details below).

You are entitled to request access to your clinical records. We request that you put your request in writing and we will respond to it within a reasonable time.

There may be a fee for the administrative costs of retrieving and providing you with copies of your clinical records.

We may deny access to your clinical records in certain circumstances permitted by law, for example, if disclosure may cause a serious threat to your health or safety. We will always tell you why access is denied and the options you have to respond to our decision.

If you have a complaint about the privacy of your personal information (including complaints about our use of the Myhealth record system), we request that you contact us in writing. Upon receipt of a complaint we will consider the details and attempt to resolve it in accordance with our complaints handling procedures.

If you are dissatisfied with our handling of a complaint or the outcome you may make an application to the Australian Information Commissioner or the Privacy Commissioner in your State or Territory.

We will not transfer your personal information to an overseas recipient unless we have your consent or we are required to do so by law.

Please direct any queries, complaints, requests for access to medical records to:

info@head2toefamilyhealth.com.au

By signing my name below, I certify that I have read the above information. Any questions concerning this Privacy Policy and Service Agreement have been discussed. My signature also certifies my understanding of and agreement with the above policy.