The Snowflake Clinic Group Program Form

The Snowflake Clinic

Expression of Interest for

Group Programs in 2020

by Telehealth / Videoconference

Are you or the Participant registered with the National Disability Insurance Scheme (NDIS)? *

YesNo

Which age group are you interested in? *

Which groups are you interested in? (You can select more than one, and we will e-mail you further information)

AUTISM: Anxiety, Anger & Mood ManagementAUTISM: Social SkillsOTHER DISABILITY: Anxiety, Anger & Mood ManagementFOR CARERS: Carers Taking Care Of Themselves

Which groups are you interested in? (You can select more than one, and we will e-mail you further information)

AUTISM: Anxiety, Anger, Stress & Mood ManagementAUTISM: Social Skills For TeensAUTISM: Eating DisordersOTHER DISABILITIES: Anxiety, Anger, Stress & Mood ManagementOTHER DISABILITIES: Eating DisordersALL DISABILITIES: Grief and LossFOR CARERS: Carers Taking Care of Themselves

Which groups are you interested in? (You can select more than one, and we will e-mail you further information)

AUTISM: Anxiety, Anger, Stress & Depression ManagementAUTISM: Navigating Life (includes social skills, relationships, employment etc.)OTHER DISABILITIES: Anxiety, Anger, Stress & Depression ManagementALL DISABILITIES: Addiction (Alcohol and Drug Abuse)ALL DISABILITIES: Grief and LossFOR CARERS: Carers Taking Care of Themselves

Which groups are you interested in? (You can select more than one, and we will e-mail you further information)

AUTISM: Anxiety, Anger, Stress & Depression ManagementAUTISM: Navigating Life (social skills, relationships, employment, etc.)OTHER DISABILITIES: Anxiety, Anger, Stress & Depression ManagementALL DISABILITIES: Addiction (Alcohol & Drug Abuse)ALL DISABILITIES: Grief & LossFOR CARERS: Carers Taking Care of Themselves

Which groups are you interested in? (You can select more than one, and we will e-mail you further information)

Anxiety & Mood ManagementAnger ManagementFOR PARENTS & CARERS: Parenting Strategies

Which groups are you interested in? (You can select more than one, and we will e-mail you further information)

Anxiety, Stress & Mood ManagementAnger ManagementEating Disorders (male and female)Grief & LossFOR PARENTS & CARERS: Parenting Strategies

Which groups are you interested in? (You can select more than one, and we will e-mail you further information)

AnxietyDepressionStressAngerEating Disorders (male and female)Addiction (Alcohol & Drug Abuse)Grief & Loss

Which groups are you interested in? (You can select more than one, and we will e-mail you further information)

AnxietyDepressionStressAngerEating Disorders (male and female)Addiction (Alcohol & Drug Abuse)Grief & Loss

Personal Details

Are you filling in this form for yourself or for someone else? *

MyselfSomeone else

Participant's first name *

Participant's last name *

Participant's Date of Birth *

Participant's Gender

Participant's Medicare Card Number

The number next to the Participant's name on the Medicare card

Expiry date on the Participant's Medicare card

Participant's NDIS Registration Number

Is the Participant's NDIS plan ...

Self-managedPart-managed by another organisationFully managed by the NDISUnsure

If the NDIS is part-managed by another organisation, please provide details (such as organisation name, contact person, phone number etc.)

Participant's Address (include state and postcode if known) *

What is your relationship to the Participant? *

Mobile Phone Number *

Other phone number (include area code for landline numbers)

Email Address *

Are these contact details yours or the Participant's? *

MineThe Participant

Please upload a copy of the participant's NDIS plan here by clicking on the "Browse" button to search your computer or phone files

Browse

If you are unable to attach your NDIS plan at the moment, that's OK. But doing so will enable us to ensure that your chosen program(s) will meet the goals specified in the plan.

Your first name *

Your last name *

Your date of birth *

Your gender

Your Medicare card number

The number next to your name on the Medicare card

Expiry date on your Medicare card

Your NDIS registration number

Is your NDIS plan ...

Self-managedPart-managed by another organisationFully managed by the NDISUnsure

If the NDIS plan is part-managed by another organisation, please provide details (such as organisation name, contact person, phone number etc.)

Your address (include state and postcode if known) *

Your mobile phone number *

Other phone number for you (include area code for landline numbers)

Your e-mail address *

Emergency Contact Name & Relationship to the Participant

Emergency Contact Phone Number

Please upload a copy of your NDIS plan here by clicking on the "Browse" button to search your computer or phone files

Browse

If you are unable to attach your NDIS plan at the moment, that's OK. But doing so will enable us to ensure that your chosen program(s) will meet the goals specified in the plan.

If you have one, please upload a copy of the GP or specialist referral and/or Mental Health Treatment Plan by clicking on the "Browse" button to search your computer or phone files

Browse

If you do not have a referral or Mental Health Treatment Plan yet, that's OK. But if you do, uploading it now will enable us to ensure that everything is in order with Medicare so that a rebate can be given as quickly as possible.

Other Group Information

Preferred Days & Times To Attend Online Groups (please choose at least three options if possible)

Any weekday morningAny weekday afternoonAny weekday eveningMonday morningMonday afternoonMonday eveningTuesday morningTuesday afternoonTuesday eveningWednesday morningWednesday afternoonWednesday eveningThursday morningThursday afternoonThursday eveningFriday morningFriday afternoonSaturday morningSaturday afternoon

Write any notes about your preferred dates and times here

Would you prefer the group to be ...

All FemaleAll MaleFemales and MalesDoesn't matter

Brief Medical History

Is the Participant currently taking any medications?

YesNo

Please list medications

Does the Participant have any allergies?

YesNo

Please list allergies

What diagnoses has the Participant been given? Please list

Are you currently taking any medications?

YesNo

Please list your medications

Do you have any allergies?

YesNo

Please list your allergies

What are your diagnoses? Please list

Is there anything else we should know? If so, please describe

Consent

I, the undersigned, certify that I (or my dependent) understand that the information I have given today is correct to the best of my knowledge. I also understand that this information will be treated confidentially by The Snowflake Clinic. I am aware of the limits of confidentiality, including in the event that there is a concern for someone's welfare, information may need to be provided to others in order to keep someone safe. Further details about privacy and confidentiality are available on the The Snowflake Clinic's website at: http://www.snowflakeclinic.com.au/other-information.html . It is my responsibility to inform the Snowflake Clinic of any changes in my personal circumstances.

Signature *

Clear signature

Your name *

Date *