Client Information Form Client Information Form Kids@Heart Client Information: First Name*Last Name*Gender*MaleFemaleDate of Birth* DD MM YYYY Country of BirthArrival in AustraliaLanguages spoken at homeHome Address* Street Address City State / Province / Region ZIP / Postal Code Parent Information: Mother's NameAddress (if different to above) Street Address City State / Province / Region ZIP / Postal Code Phone NumberOccupationEmail Father's NameAddress (if different to above) Street Address City State / Province / Region ZIP / Postal Code Phone NumberOccupationEmail Living Arrangements: Client Lives with:Custodial order in place:YesNoN/APlease Specify: Referring Provider: PractitionerProvider NoPractice / ClinicAddress Street Address Phone NumberFaxReferral Date Please note: referral letter is required by first appointment - please bring or alternatively email the referral letter. Client Covered by: Eligible for: Better Access to Mental Health - Medicare Helping Children with Autism - Increased Access to Diagnosis - Medicare Helping Children with Autism - Increased Access to Treatment- Medicare Private Health Insurance Private Fee Paying NDIS - Self Managed only Unsure? Clients Medicare Details: Medicare NoReference ID NoExpiry Date* Parents Medicare Details: Medicare NoReference ID NoExpiry DateClaimant (Parent) NameClaimant (Parent) Date of Birth Education Setting: School NamePhone NumberYear LevelContact PersonContact Person Email Address Services and Other Professionals Involved: NameDisciplinePhone NumberPractice / ClinicEmail AddressNameDisciplinePhone NumberPractice / ClinicEmail AddressNameDisciplinePhone NumberPractice / ClinicEmail AddressNameDisciplinePhone NumberPractice / ClinicEmail Address Other Comments or Helpful Information: Please specify With thanks, Dr Michelle Rowland
