TERM 1, 2025 - Sense Therapies Program of Support TERM GROUPS - Intake Form & Client Service Agreement

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 *

TERM 1 Programs of Support Group Selection - FULL TERM COMMITMENT *

Mondays : Sense STRENGTH - Ages : 10yrs+ 3:30pm - 5:00pm - COST $120 per session (03.02.2025 - 07.04.2025) Mondays : **FULL WAITLIST ONLY** Sense TEEN BOYS - Ages : 13yrs+ 3:30 - 5pm - COST $120 per session (03.02.2025 - 07.04.2025) Wednesdays : Sense PRESCHOOL - Ages : 3yrs-5yrs -10:00am - 11:00am - COST $120 per session (05.02.2025 - 09.04.2025) Wednesdays : Sense TEAM SPORTS - AFL - Ages : 4yrs-7yrs - 3:30pm - 4:30pm - COST $80 per session (05.02.2025 - 09.04.2025) Wednesdays : Sense TEAM SPORTS - AFL - Ages : 8yrs+ - 4:30pm - 5:30pm - COST $80 per session (05.02.2025 - 09.04.2025) Thursdays : **EXRESSIONS OF INTEREST ONLY** - Sense Bikes - Ages : 7yrs - 12yrs - 3:30pm - 5:00pm COST $120 per session (06.02.2025 - 10.04.2025) Thursdays : **EXRESSIONS OF INTEREST ONLY** Sense PRESCHOOL - Ages : 3yrs-5yrs - 11:00am - 12:00pm - COST $120 per session (06.02.2025 - 10.04.2025) Fridays : Sense SURF - *FULL WAITLIST ONLY* Ages : 5yrs-7yrs - 3:30pm - 4:30pm - COST $95 per session (07.02.2025 - 11.04.2025)Fridays : Sense SURF - *FULL WAITLIST ONLY* Ages : 8yrs+ - 4:30pm - 5:30pm - *FULL WAITLIST ONLY* COST $95 per session (07.02.2025 - 11.04.2025)

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? *

Funding (as applicable) *

NDIS Plan ManagedNDIS Self Managed Plan - Payable on the day or Direct DebitPrivate Health Insurance - Payable on the day or Direct DebitOther Funding - eg Medicare - Payable on the day or Direct DebitSelf Funded (out of pocket) - Payable on the day or Direct Debit

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) *

INVOICE PAYMENT PAYABLE ON DAY OF SERVICE PROVISION - applicable to all non Plan Managed Participants either via Direct Debit or TAP & GO *

YES N/A - I am Plan Managed

PROGRAMS OF SUPPORT

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).

**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**

*

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.

*

Injury Waiver Form
I have read and understand the Sense Therapies Clinic Injury Waiver Form - this includes use of & not limited to the following &/or similar : Tampoline, Foam Pit, Swings, Rock Wall, Slide, Lycra Hammocks, Soft Play Equipment, Lofts (located on the Sense Therapies website). I understand that this form has to be completed and signed before the first session. *

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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