Home Care Package - Consent Form

The Enable Occupational Therapy consent form is a document that outlines the purpose, procedures & policies of engaging in our services. By signing, individuals acknowledge their understanding and accept all of Enable Occupational Therapy's policies. Enable Occupational Therapy ensures the individuals of their rights and maintains a high standard of confidentiality.

Client Details

Client First Name *

Client Surname *

The Person that is Authorised to sign this Consent Form is:

The Client? *

The Authorised Representative? *

Clients Authorised Representative *

and Practice Name

Consent Form Purpose

This Consent Form is made for the purpose of informing individuals about Enable Occupational Therapy's processes, procedures and policies, to ensure smooth delivery of services.

Contact Details

Client First Name

Client Surname

Client Date of Birth *

Phone

Email

Address *

Client' Representative Name

Client Representative Phone *

Client Representative Email *

Client Representative Address

Relationship to Client

Consent

At times, it may be helpful for us to talk with other people involved in your care. Only information relevant to the service we are providing will be discussed. We will not talk with anyone that you do not want us to speak with.

The Client/Client Representative consents to Enable OT liaising with:

Funding

Please prepare my funding in

Total Hours *

Budget Allocation Dollars

Occupational Therapist

Email

Type of Support:

Clinical assessment and treatment
Clinically relevant communications including phone calls/written programs/communication with other health professionals (any task that takes more than 6 minutes will be invoiced)
Attendance at team meetings/case conferences
Assessment and trial of equipment as required
Any reports, forms, or letters as required by the Case Manager or requested by the client / client representative
Cancellation charges for late notice or no show appointments

Enable OT reserves the right NOT to provide service or to cancel any future appointments for the client if you do not have sufficient funds.

Price and Payment Information:

The hourly rate, travel rates and guidelines for services included (including cancellation policy) are subject to change. The fees are:

Occupational Therapy: $193.99 per hour plus $193.99 per hour for any associated therapist travel.

If any Enable OT Therapist arrives to a confirmed appointment, and the Client declines service, is not present or does not show up after contact attempts, then both non-attendance of the appointment and any relevant travel will be charged.

Payments

Enable OT will seek payment for their provision of supports after the supports have been delivered.

Funding Management Type *

My Aged CareOther

Funding Other

Name of person/organisation paying *

Phone of person/organisation *

Email of person/organisation paying *

Rights & Responsibilities

Enable OT agrees to;

Provide Therapy services as per this agreement.
Work in collaboration with you to achieve your goals.
Communicate openly and honestly with you.
Be polite and friendly and treat you with respect at all times.
Explain things clearly so you understand every step of the process.
Include you in all decisions about your supports.
Listen to your feedback and act quickly upon any complaints you report to us.
Store your information carefully and maintain your privacy.

You agree to;

Notify Enable OT about any changes you wish to be made to this Service Agreement.
Provide at least 24 hours notice if you wish to cancel a booked service.
Provide at least 24 hours notices if you wish to terminate our services. You will be billed for the hours of service provided to the date of termination.
Pay invoices by the due date.

Cancellation Policy

Short notice cancellations or non-attendance, where notice is given with less than 1 clear business day before the scheduled appointment, may result in 100% of the appointment fee being charged (except in extenuating circumstances), including any travel (or part thereof) already undertaken.

If there are frequent cancellations, Enable OT will contact you to try to understand why they are occuring and see if anything needs to change in the delivery of the therapy services to support the Client.

Outstanding Fees

Outstanding fees need to be paid prior to further services being provided. If fees are not paid, Enable OT may contact the following (where applicable) to recover the outstanding debt:

Debt collector
The Client/Client's Representative will be liable for the costs associated in recovering such debts

Making a Complaint

We will strive to ensure that your experience with Enable OT is a positive one, however in any instance where you are unhappy with our service, feel free to discuss this with us as soon as possible. Please be assured that we welcome all feedback and will endeavour to resolve any issues or concerns in a timely manner.

If any Parties have a concern, you can speak directly to the Enable OT Director:

Janelle Brumpton
T: 03 4310 1340
E: janelle@enableoccupationaltherapy.com.au

If changes to the supports or their delivery are required, the Parties agree to discuss and the 'Services'. The Parties agree that any changes to the 'Services' will be in writing, signed, and dated by the Parties.

Ending the 'Services'

Should either Party wish to end the 'Services' they must give 48 hours notice.

If either Party seriously breaches the policies and/or procedures, the requirement of notice will be waived.

Form: 0005 Title: HCP Consent Form Last updated: 19 Nov 24

Signatures

Are all details correct? *

Signature

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Client

Date

Review Note

I consent for my Signed Consent Form to be provided to my Representative

Client Representative Email

By signing this Consent Form, you agree to all of the information included.

Please note, if we do not receive back a signed copy of this Consent Form and the Client continues to attend appointments after receiving, it is implied the Client / Client's Authorised Representative have accepted the terms within this document.

I have read & understood the terms and understand each item listed within. I understand Enable OT will be engaged to provide services that it is entitled to receive payment in return.

I confirm that authority has been delegated to me the undersigned, to represent the Client and execute this Consent Form as the Client's Authorised Representative.

Signature

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Client Representative

Date

Signed on behalf of:

Client

Date

Thank you - we will review your response promptly and return an updated form for you to approve .

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