Private Therapy Referral Form

Thank you for choosing Firstchance. The details gathered on this form will assist us to:

Connect you with most appropriate staff member to provide supports to your child and family.
Put together an initial quote for services.

Please note: We like to advise all privately funded families that the most affordable option is to receive services at the Firstchance office, located in Mayfield. Any supports provide outside of the clinic incur an ADDITIONAL CHARGE.

If you have questions, or need support to complete this form, please don’t hesitate to contact our Finance Team on 02 4910 3130 or email fc-accounts@firstchance.org.au and we can walk you through it or complete the form on your behalf.

Primary Carers Details

Full Name *

Phone Number *

Email Address

Relationship to child *

Address (if different from child's)

Child's Details

First Name *

Surname *

Date of Birth *

Gender *

Street Address *

Suburb *

Postcode *

Does your child have a diagnosis? *

If 'YES' please provide information relating to diagnosis *

If 'NO' please provide information relating to your concerns for your child *

File Upload - Please attach a copy of any reports or assessments that provide information about your child's diagnosis or developmental/behavioural concerns. Reports help us to make informed decisions about suitable pathways for support.

Browse

Supports Required

Please indicate which service/s you require *

Occupational TherapySpeech PathologyOne Off Assessment

What skills/areas are you wanting to work on during these sessions *

Support Preferences

Rates:

Our current rate is $193.99 per hour of support - 45minutes face-to-face & 15minutes of report writing.

If chosen to have supports provided in a home or school/preschool setting, this will include an ADDITIONAL CHARGE of the travel time it takes for our team memeber to drive there.

Preferred Location for Sessions *

Firstchance OfficeHomeSchool/Preschool

School/Preschool Name *

Frequency of sessions *

WeeklyFortnightly Other (please specify)

Other *

Preferred start date

Estimated number of sessions you require

How will you be paying for sessions? *

Please upload a copy of GP referral

Browse

Additional Information: Please add anything else you would like to share about the child/family.

How did you hear about Firstchance? *

If "other" please provide details: *

Save and Complete Later