Sense Therapies TERM 3, 2025 Groups - Intake Form & Client Service Agreement - Programs of Support

How did you hear about Sense Therapies? *

Participant First & Preferred Name : *

Participant Last Name *

Participant D.O.B *

Pronouns

Primary Carer/Guardian First Name *

Primary Carer/Guardian Surname *

Primary Carer/Guardian Email *

Primary Carer/Guardian Mobile *

Relationship to Participant *

Address *

Street address *

City *

State *

Postcode *

Secondary Contact - First & Surname *

Secondary Contact Mobile *

Secondary Contact - Email *

Secondary Contact - Relationship to Participant *

**Full Details TBC** SENSE STRENGTH : $120 p/session : 1.5hrs - Location : NSPC Gym Bull (next door to Clinic) & Shamrocks Rugby Oval, Campbell St, Woonona

MONDAYS - Ages : 10yrs+ - Time : 3:30pm - 5:00pm - 21.07.2025 - 22.09.2025

SENSE PRESCHOOL : $120 p/session : 1hr - Location : Sense Therapies Clinic 237 Princes Hwy BULLI

WEDNESDAYS - Ages : 3yrs - 5yrs - Time : 10:00am - 11:00am - 23.07.2025 - 24.09.2025

SENSE AFL : $80 p/session : 1hr - Location : Shamrocks Rugby Oval, Campbell St, WOONONA

WEDNESDAYS - Ages : 4yrs - yrs - Time : 3:30pm - 4:30pm - 23.07.2025 - 24.09.2025WEDNESDAYS - Ages : 8yrs + - Time : 4:30pm - 5:30pm - 23.07.2025 - 24.09.2025

** Expressions of Interest ** SENSE GIRLS: $125 p/session : 1hr - Location : Sense Therapies Clinic 237 Princes Hwy BULLI

FRIDAYS - Ages : 7-9yrs - Time : 3:30pm - 4:30pm - 25.07.2025 - 26.09.2025 **EXPRESION OF INTEREST ONLY**

Does the Participant have any SPDR &/or Allergies? *

YesNo

If YES, please specify SPDR &/or Allergies

What would you like the Participant gain from partaking in Sense Therapies Groups? e.g. Social, Gross motor, Emotional Regulation, Sensory Processing Skills, Goals etc (OR CURRENT PARTICIPANT) *

What would you like our Therapy Team to know about the Participant? (OR CURRENT PARTICIPANT) *

Do we need to be aware of any risks? e.g. allergies, seizures, tendency to abscond or become aggressive if the demand is too high? Please note any triggers you are aware of (OR CURRENT PARTICIPANT) *

How can we best support/encourage the Participant? (OR CURRENT PARTICIPANT) *

Please specify any diagnoses, pre-existing &/or new injuries we need to consider in how we plan the sessions *

Is there anything the Participant would prefer NOT to partake in? *

PAYMENT - note : ALL NON-Plan Managed Participants must make either make payment on the day (IN-CLINIC activities), direct debit (NOTE : OUT OF CLINIC activities must be paid on invoice) *

NDIS Plan ManagedNDIS Self Managed Plan - SEE ABOVEPrivate Health Insurance - SEE ABOVESelf Funded - including all Health Care Plans (out of pocket) - SEE ABOVE

NDIS Number - ENSURE DETAILS CORRECT & COMPLETE (If applicable) *

Where to email Invoices : Plan Manager or Participant/Guardian's email *

NDIS Plan End Date - ENSURE DETAILS CORRECT & COMPLETE (If applicable) *

NDIS Plan Start Date - ENSURE DETAILS CORRECT & COMPLETE (If applicable) *

DIRECT DEBIT/AUTO-PAYMENT – Available to all NON-NDIS Plan Managed Participants. As invoices are payable on issue, Sense Therapies use a Direct Debit system as preference. Session payments are processed after each session. Payment receipts are emailed & can then be used to lodged/claimed as you wish. Please speak with our Admin Team to provide your details either by email, SMS or phone call. *

YesNoN/A - I am Plan Managed

PROGRAMS OF SUPPORT & CANCELLATIONS

All Sense Team Sports, Term Groups & Holiday Activities including Camps are goal orientated, skill based & delivered as Programs of Support.

Programs of Support are delivered as intensive group therapy for a specific period range (no longer than 12 weeks) with a definite start and finish date.

The inclusive period for each Group/Activity offered by Sense Therapies is detailed in the individual Intake Forms, Confirmations & Itinerary communications – prior to commencement.

In acceptance of participation in Programs of Support Participants agree to be charged for the service provided, regardless of attendance/non attendance - as long as the provider had the capacity to deliver the support/activity (or an alternative) was delivered.

Through utilising the Program of Support model, we can both maximise therapeutic benefit and ensure fair pricing for all Participants. (as per NDIS Price Guide).

Participants must notify Sense Therapies of withdrawl from the Program of Support seven (7) business days PRIOR to the commencement date of each individual camp day confirmed otherwise the Participant agrees 100% of the total fee of Holiday Camp period is payable, regardless of attendance.

**Programs of Support may be covered under the NDIS Capacity Building OT Group rate, provided the Participant has the allocated funding. As individual NDIS Plans differ, we suggest checking that the correct funding is available in the Participant's Plan prior to signing up**

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Cancellation/Withdrawal Policy - Sense Team Sports & Term Groups

Once the Participant’s inclusion in the Group has been confirmed by Sense Therapies & accepted by the Participant, all stipulations in the Cancellation Policy will apply, regardless of attendance or non-attendance.
Lack of response to any & all confirmations will not suffice as rejection or withdrawal of the Intake Form submitted.
ALL requests forcancellation/withdrawal from confirmed Sense Team Sports & Term Groups must be provided in writing via email - prior to the cut off period to avoid cancellation costs.
Participants must notify Sense Therapies of withdrawl from Sense Team Sports & Term Groups 14 full business days PRIOR to the commencement dates of the agreed commencement date to avoid cancellation costs.
Failure to provide less than 14 full business days notice of withdrawal from Sense Team Sports & Term Groups will be subject to the Cancellation Policy.
Participants wishing to exit the Sense Team Sports & Term Groups after the commencement/during the inclusive dates will incur a two (2) weeks cancellation fee regardless of attendance or non-attendance.

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INJURY WAIVER

I give permission for the Participant to partake in Sense Therapies Group Program/s. I understand every effort will be made by Sense Therapies to minimise the possibility of injury, I understand some degree of risk remains inherent in participation in the program/s. I understand I am responsible for remaining present (or close by, as agreed) during sessions & ensuring the Participant's safety.

NOTE : This waiver applies to all individuals, including the listed Participant, who are involved/partaking in any way with Sense Therapies activities, whether on or off the premises.

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PERMISSION TO PARTICIPATE IN SENSE THERAPIES GROUP PROGRAMS

I give permission for the Participant to partake in Sense Therapies Group Program/s.

While I appreciate every effort will be made by Sense Therapies to minimise the possibility of injury, I understand some degree of risk remains inherent in participation in the program/s. I understand I am responsible for remaining present (or close by, as agreed) during sessions & ensuring the Participant's safety.

*

Do you give permission for Images, Video and/or Audio of the Participant be utilised on Social Media and Public Platforms? I understand there is no time or geographical limit on the validity of my permission. *

YesNo

WAIVER OF FINANCIAL GAINS
I understand that the Participant & any associates, including myself, waive all rights to all royalties & related financial related domains. *

Carer Signature: *

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Date of Submission *

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