Parent Name*

First Name Last Name

Mobile number*

Parent Email (where general info + Parent form will be sent)*

Do you give permission for Jump Up OT to contact your child's teacher or other relevant school staff:*

Yes - you can contact the teacher
No - please don't contact the teacher

What is the name of the school/kindy/childcare your child attends

Suburb of school

Teacher's name

First Last

Teachers Email (where the teacher forms will be sent)

Child 1 Full Name*

First Last

Child 1 Gender*

Male
Female
Gender not disclosed

DOB*

Year level at school

Select the child's presenting issues

Details of presenting issues

Funding/Rebate type (determines the auto email they are sent):

No Rebate (they will pay sessions in full)
Helping Children with Autism (HCWA) or Better Start funding
EPC (Enhanced Primary Care Plan from GP)
Private Health Insurance
NDIS

NDIS Management

Allocated OT

Madeline
Kaitlyn
Jennie

Occupational Therapy - Schedule of Fees
(commencing 01 January 2021)

Clinical Fees

Initial consultation and written summary (including goal setting)	$575
Feeding/toileting initial consultation	$300
30 minute follow up session	$97
45 minute follow up session	$145
1 hour follow up session	$193
45 minute group follow up session	$95/child

Clinical Administration Fees

Review report	$180
Letter (requested by parents)	$70
Phone consultation (up to 30 min)	$60

Travel Fees

Charged in addition to session costs for kindy, school and home visits.

Distance will be determined from Bald Hills clinic (Attunga St, Bald Hills).

$30	Up to 30km return
$50	30-40km return
$70	40-60km return

Travel beyond 60km return will be negotiated on a case by case basis with the Director, Jump Up For Kids

Cancellation Policy

A minimum of 24 hours notice is required if you wish to cancel or reschedule an appointment.

The full consultation fee will be charged if the appointment is cancelled with less than 24 hours notice.

The $50 booking deposit will be forfeited, if the first appointment is cancelled, regardless of time of cancellation.

Please note, if we see your child at their school, it is the parent’s responsibility to let us know of school events that may interfere with their regular appointment time (eg special assemblies, Xmas concerts, excursions etc). It is not the teacher's responsibility to let us know and we are not able to change appointment times without notice.

Will travel fees be charged?*

No
Yes

What is the agreed rate to be charged?*

Zone 1: Up to 30 km return ($30)
Zone 2: 30-40 km return ($50)
Zone 3: 40-60 km return ($70)
Other

Please enter more information*

Will $7.50 room rate fee be charged? (All Saints clients only)*

No
Yes

Phone Intake Form

When you complete this form the client’s parent and the teacher will both receive information emails with their relevant surveys to complete. The form will also be saved into Trello to ensure it is followed up on

Occupational Therapy - Schedule of Fees
(commencing 01 January 2021)

Phone Intake Form

When you complete this form the client’s parent and the teacher will both receive information emails with their relevant surveys to complete. The form will also be saved into Trello to ensure it is followed up on

Occupational Therapy - Schedule of Fees(commencing 01 January 2021)

Occupational Therapy - Schedule of Fees
(commencing 01 January 2021)