The Snowflake Clinic


Expression of Interest for

Group Programs in 2020

by Telehealth / Videoconference


Personal Details


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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.
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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.
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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

Brief Medical History

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.

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