Client Information and Service Enquiry Form

Life Skills Hub specialises in catering to young people aged 7-25+.

If you have a child who is under this age, please contact our friendly admin team on 8180 0761 or via email at admin@lifeskillshub.com.au. In some circumstances, we may be able to support children from 5 years of age depending on the individual and services requested.

Referrer Details

Who is completing this form? *

I am the client I am the parent/guardian of a child or young personI am another professional completing the referral

Consent must be provided by the client. Please note that a copy of this form will be emailed directly to the client upon completion.

First Name *

Last Name *

Email Address *

Relationship to client *

Client Details

First Name *

Last Name *

Known as

DOB *

Pronouns

Primary Address

Postcode

Email Address *Note this email will be the one which receives a copy of this form.

Phone Number. *

Medicare Number

Reference Number (number next to name)

Religion

Languages spoken at home

Name of School (if applicable)

Do you identify as Aboriginal or Torres Strait Islander (optional)

AboriginalTorres Strait IslanderAboriginal and Torres Strait IslanderNo

What is your cultural identity?

Do you have any cultural requirements we can assist with?

Are there any current or pending family court orders? *

YesNo

Please upload any relevant documentation.

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What are your interests?

Medical Information

List any relevant medical information

Please provide copies of specialised medical plans e.g. asthma management, anaphylaxis

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Dietary Requirements

List any intolerances and allergies:

Current Supports

Please let us know of any current supports the client has in place and their contact details. For example, Paediatrician, Occupational Therapist, Speech Pathologist, Positive Behaviour Support Practitioner etc.

You can add additional names by selecting "add item"

Service Type (i.e. OT, Speech, Paeadiatrician)

Name of Practitioner

Company Name

Contact details (phone or email address)

Communication Preferences

I (the client) would like to receive all SMS reminders and communications.I would like to nominate another adult to receive SMS reminders and communications (i.e. caregiver or supportive adult- see section below)

Please indicate preferred method of contact

PhoneEmailText

If under 18 years/or if a support person has been nominated, please complete the section below.

Please note that for young people under 18 years it is the primary parent/caregiver/supportive adult who:

will receive SMS reminders for sessions;
is responsible for communicating details of sessions to the other parent (if applicable);
is responsible for all Life Skills Hub accounts

Primary Parent / Caregiver / Supportive Adult (if applicable)

Full Name

Relationship to young person

Address

Postcode

Phone

Email Address

Second Parent / Caregiver / Supportive Adult (if applicable)

Full Name

Relationship to young person

Address

Postcode

Phone

Email Address

Emergency Contact

(Person other than caregiver, e.g. Sibling or Grand Parent)

Full Name *

Relationship to young person *

Phone *

Do you consent to Life Skills Hub discussing sessions and/or confidential information with this person? *

Yes No

Do you consent to this person collecting your child from their session in an emergency situation? *

Yes No

Payment

Please note we are unable to see clients who are NDIS agency managed.

How will appointments be funded? *

PrivateNDIS - Self managedPlan Managed / Third Party Managed Other

Please provide the details of the third-party agency below:

Agency Name

Phone

Address

Postcode

NDIS Number

Plan Start Date

Plan End Date

Please provide us with a copy of your NDIS goals

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Our Services

We would like to know what services you are interested in.

Please select all services of interested in the following sections. *Detailed descriptions are available on our website.

1:1 SERVICES

1:1 services are booked in 10 session blocks (either weekly or fortnightly). Ongoing blocks will be offered if appropriate as determined at 8th session.

Occupational Therapy
OT services assist children and young people to achieve their daily occupations. This may include support in the areas of sensory processing, motor skills, self-care skills, social skills and play.

Additional Information / Other

Functional Capacity Assessment (FCA)

A Functional capacity assessment (FCA) is comprehensive assessment of a person’s current skills to identify any areas which they may require additional support or assistance. An FCA evaluates a person’s level of independence to perform daily tasks that they may need or want to do in the home, community and work (if applicable).
Note: All FCA's will take a minimum of 10 hours for assessment, scoring and reporting.

Reason for seeking a Functional Capacity Assessment (select all that apply) *

It was requested by the National Disability Insurance Agency (NDIA)Seeking evidence for increased funding in my planI am unsure Other (please specify below)

What does the client hope to achieve from the assessment? *

Allied Health Assistance
A therapy assistant delivers a therapy plan on behalf of a therapist (e.g. Occupational Therapist, etc). This is a cost-effective way to receive therapy. *please note that a qualified Allied Health Professional needs to determine this service to be appropriate.

Psychology
To provide therapeutic interventions for young people experiencing behavioural, social, emotional or educational difficulties.

Additional Information / Other

Feeding Therapy
Provided by one of our Allied Health Professionals and/or AHA's, feeding sessions will support young people to develop increased comfortability wih new or unfamilar foods in hopes to expand the variety in their diet. This may be done through education, creative play and cooking sessions. *please note: Life Skills Hub does not assess for, or address swallowing difficulties.

What areas would you like to address in feeding therapy? *

Oral motor skills: Difficulty chewing or managing food in mouth (note: Life Skills Hub does not address swallowing). Sensory Based Food Challenges: Avoidance of certain textures, strong food preferences, or gagging on specific foods. Picky Eating & Food Variety: Limited diet, refusal of certain foods or food groups, or difficulty trying new foods. Behavioural & Emotional Aspects of Eating: Anxiety, distress, mealtime struggles or refusing to eat. Transition to Oral Feeding: Support for children transitioning from tube feeding to eating by mouth. Mealtime Routines: Challenges with structured meals at home, school or in social settings. General Feeding Concerns: Unsure if feeding difficulties are typical or need professional support.Other (please specify below)

Additional Information / Other

Dietetics
Dietitians work with clients to develop positive relationships with food to improve health, wellbeing and independence through nutritional therapy. This may include assessment of nutritional needs, eating behaviours, dietary intake advice and interventions to support client goals.

What areas would you like to address in dietetics ?

Fussy Eating & Expanding Food Variety – Support for selective eaters to try new foods and improve dietary variety (please select Feeding Therapy above to provide more information).Nutrition for Growth & Development – Ensuring children and young people receive adequate nutrition to support their health, energy, and development.Food Allergies & Intolerances – Guidance on safe eating, substitutions, and balanced nutrition with dietary restrictions.Gastrointestinal & Digestive Health – Managing gut health concerns such as constipation, reflux, bloating, or food intolerances.Healthy Eating Habits & Meal Planning – Support with balanced meals and family mealtime routines.Weight Management & Body Confidence – Guidance on supporting a optimal weight while promoting body confidence and a positive relationship with food.Mealtime Routines & Independence – Encouraging self-feeding skills, structured mealtimes, and positive mealtime experiences.

Additional Information / Other

Onsite Mentoring

Sessions with a trusted person to assist in building social skills, resilience and share in activities of interest, as well as offering opportunities to try new experiences.

Offsite Mentoring
Sessions with a trusted person at another location such as home or in the community. These sessions endeavour to assist young people to engage in the community, build skills within the home, explore interests and try new experiences. Please note : Mentoring services differ from support work. Depending on client needs and goals, mentoring queries may be re-allocated to Allied Health Assistance.

Additional Information / Other

OT Student Program
Cost-effective OT services provided by final year occupational therapy student. This may work alongside your existing therapy supports. This service may not be sutiable for all clients and an intake process is required.

Type of Service (tick all that apply):

Onsite services at Life Skills Hub Elizabeth ValeHome-based servicesSchool-based servicesCommunity-based services

Please note, group-based services are only provided onsite.

The provision of offsite services is dependent on suitability and service availability. Further information will be requested following the review of this form.

Please list the home suburb for offsite visit: *

Name of School: *

If you have a preference for a specific clinician/staff member(s) please list this below.

THERAPY GROUPS

Small group sessions with similar aged peers facilitated by a Therapist or Allied Health Assistant. Please note, groups are allocated based on age and participants skill level as determined by an Allied Health Professional.

What’s the Buzz
The popular social skills program designed by Mark le Messurier and Madhavi Parker.

Cooking Therapy Group - Zesty Chefs
Develop specific skillsets required for meal planning and preparation. Recipes and skills can be specifically tailored to the individual based on their interest and taste.

LEGO© Therapy
A social development program designed for young people diagnosed with Autism Spectrum Disorder and other children with social communication difficulties.

Puberty Group (females)
With a qualified therapist, our budding teens’ group will aim to ensure that young women are prepared with the right information to support this life transition.

Puberty Group (males)
With a qualified therapist, our budding teens’ group will aim to ensure that young men are prepared with the right information to support this life transition.

High School Transition Group
This 10-week group supports young people to build skills required for a smoother transition to high school. The group provides opportunities for students to reflect, connect with peers and learn how to implement helpful and practical strategies.

Gross Motor Group
Develop gross motor skills and strength in a fun group setting. Sessions will include variety and expose young peo-ple to varied skills for increased opportunities for success.

STRUCTURED GROUPS

Small group sessions with similar aged peers facilitated by a therapy assistant or mentor, working towards specific goals.

Minecraft Group
A social group specifically designed by our therapists and young people with Autism. The group aims to develop social skills via a shared interest of Minecraft, and supports participants to develop skills such as confidence, negotiation and cooperation.

D&D (Dungeons and Dragons)
This social group utilises the apopular fantasy table-top role-playing game to help engage participants over a shared interest. Supports participants to engage socially and build upon their imagination.

Craft Groups
For those participants who love to get ‘crafty!’.

Holiday Hangout – School Holiday Sessions
During the school holidays, our team of therapists and mentors host fun-filled days of carefully planned activities to help young people socially connect and have fun!

Social Connection Group for Young Adults
This group has been designed to provide a safe space for young adults aged 16-25 to socially connect and engage in activities that are meaningful to them while supported by our staff. Activities will vary depending on the interests of participants and may involve onsite and offsite components

Social Connection Group - for young adult females
This group has been designed to provide a safe space for young females aged 16-25 to socially connect and engage in activities that are meaningful to them while supported by our staff. Activities will vary depending on the interests of participants and may involve onsite and offsite components

Social Connection Group - for young adult males
This group has been designed to provide a safe space for young males aged 16-25 to socially connect and engage in activities that are meaningful to them while supported by our staff. Activities will vary depending on the interests of participants and may involve onsite and offsite components

Board Game Club
Engage in a variety of board games each session to build friendships and have fun!

Additional Information

In order to ensure participants are supported appropriately, we will need to know some information about the young person:

Is the young person aware of this referral and do they consent to participate?

Do they have a formal diagnosis?If yes, please state the diagnosis and provide any relevant supporting documentation that may be useful (e.g. assessment report, school report, Allied Health report)

Please attach any relevant documentation

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Do they often become overwhelmed with emotion and display any of the following behaviours? (select all that apply)

Verbal AggressionWithdrawal / Isolation / DissociationViolent or aggressive behavioursEmotional numbing / day dreaming / unresponsivenessAbsconding / Running away

If yes, how frequently and can you identify any triggers?

Do they display violent behaviours towards others outside their immediate family? *

YesNo

Please provide further details

Do they have anxious behaviours?

YesNo

Please provide further detail about their anxious behaviours

Do they have difficulty separating from caregivers?

YesNo

Other comments: For example, helpful information, request for a particular staff member or female only groups.

Conditions of Service

Our client’s rights to be informed about the services they receive and be active participants in their therapeutic journey is important to us. As such, our staff will take the time to explain the parameters of service delivery and obtain informed consent from clients (and their parents/legal guardians where applicable), prior to the commencement of service delivery.

Privacy, Confidentiality and Information Sharing

Our staff are required to operate under legalisation set out in the Privacy Act 1988, Children and Young People (Safety) Act 2017 and ethical Code of Conduct set out by their professional regulatory bodies. Life Skills Hub only collects and stores personal and health information about our clients that is reasonably necessary for us to:

provide our clients with health care and wellbeing services;
contact our clients to provide advice or information in relation to the way in which the service will be provided;
improve the quality of our service;
document service provision;
administer and manage those services including charging, billing and collecting debts;
provide continuity of care;
convey information to a responsible person including a parent or guardian;
invoice 3rd parties; and
as required by Australian law.

Our staff treat client information as sensitive and are committed to protecting client confidentiality and privacy, and will take reasonable steps to ensure secure collection, storage and use of all client information. Where risk of harm to clients or others is identified within the course of service delivery, staff are legally obligated to report such risk under Australian Law. If you would like to read in detail about our Privacy, Confidentiality and Information Sharing policies, please visit www.lifeskillshub.com.au/privacy or request a copy from our team.

Clients under 18 years of age and family services

Life Skills Hub views the role of parents/caregivers and family members in supporting children and young people within service involvement as integral and will endeavour to work with children, young people and their families to promote best outcomes. Your child/young person’s clinician or mentor will speak with you and your child in your initial session about information sharing and collaborative processes in order to develop a plan that reflects your family’s unique needs.

Life Skills Hub views child and young peoples’ right to privacy within service delivery as paramount. Where appropriate and with consent, progress updates will be provided to attending parents/caregivers. Non-attending parents may request treatment information. All information shared will be done only in the young person’s best interest.

It is important that Life Skills Hub has up-to-date information regarding client’s circumstances and request that legal guardians provide relevant information in a timely and accurate manner (this includes changes to family unit or living/health care decision making responsibilities). In the absence of any court orders stating otherwise, or reasonable suspicion of risk, both legal parents/guardians have equal rights to access services and/or information pertaining to their child. Life Skills Hub will work with both parents in a respectful and professional manner, and will maintain confidentiality of each parent/caregiver throughout service delivery. We thank you for your cooperation.

Cancellation Policy

Life Skills Hub requires 48 hours’ notice of a cancellation where possible, so that we have enough time to offer the session to another client. Failure to provide appropriate notice for 1:1 services will result in a cancellation fee as per the table below:

48+ hours notice	No cancellation fee
24 - 48 hours notice	90% of intended fee
24 hours or less	100% of intended fee

Non-attendance without notice or cancellations related to group-based programs that have been committed to, will incur a cancellation fee of 100%.

In the event of repeated non-attendances (3 consecutive non-attendances without sufficient notice or less than 50% attendance to scheduled appointments) Life Skills Hub reserves the right to discontinue services. Should discontinuation of services be required, your clinician will provide you with appropriate emergency contacts and/or external referral and/or place you on the waitlist.

Courtesy SMS reminders are sent 2 days prior to appointments. Please note that clients/caregivers are responsible for monitoring their own appointments and should not rely on SMS reminders to cancel appointments.

GROUP CANCELLATION POLICY:

If your child/young person is unable to attend a session, please contact Reception on 8180 0761 as soon as possible. As the group is methodically planned over the course of the term, it is ideal for each person to attend every session.

Missed sessions will be charged at the usual rate unless Life Skills Hub have been given two weeks' notice that the person is withdrawing from the entire program.

Your Rights

To always be treated with courtesy, respect, and understanding
For your confidential information to be protected
For you and/or your young person to be consulted with appropriately and make informed decisions
To be entitled to provide feedback, voice concerns or make a complaint to the Practice Manager if relevant, and forcomplaints to be taken seriously and responded to in a timely manner
To be communicated with openly and honestly
To be provided with fee schedules and cancellation policy prior to the scheduled appointment/s
For services to be provided in a manner consistent with all relevant laws
To request a copy of your child’s health information by completing a release of information form, and receive aresponse within no more than 20 days.

Your Responsibilities

To treat Life Skills Hub staff and visitors with courtesy and respect at all times.
To confirm your identity by providing name and date of birth as required (of both the patient and parent/ caregiver).
To advise Life Skills Hub of any change in custody arrangements or contact details.
Communicate with Life Skills Hub if you have any concerns about the service/s being provided.
To pay accounts in full on the day of the session, or if accounts are managed by a third-party ensure they are within 14 days. By attending sessions, this is indicating acceptance of the fee schedule.
To pay any debt collectors expenses incurred in attempt to recover or recovery of any overdue amounts.
To cancel the session if your child has a contagious ailment (e.g. gastroenteritis, head lice etc.).
To observe the cancellation policy and act in accordance.
To respect the rights of others.
To ask questions if you do not understand.

Acknowledgement and Consent

I acknowledge that I have read and understood all aspects of this document. All information stated on this form is true and correct. *

YesNo

If you require assistance with this form, please talk to reception.

I understand that Life Skills Hub has a cancellation policy (as outlined in this document) and failure to provide 48 hours notice will result in a cancellation fee. I understand that SMS reminders are a courtesy only and clients/caregivers are responsible for monitoring bookings and managing cancellations. *

YesNo

I understand that if I regularly cancel appointments or fail to attend, my regular therapy timeslot may be forfeited. *

YesNo

I understand all staff at Life Skills Hub are mandatory notifiers and are legally required under the Children and Young People (Safety) Act 2017 to report any suspicion of risk and harm of a child/young person and/or supporting persons (for example, parents/caregivers). *

YesNo

If I am not present on-site for the duration of my child’s appointment and there is an urgent situation, I consent to Life Skills Hub staff making decisions on my behalf. For example: assisting my child with restroom facilities if they require help, calling an ambulance in a medical emergency, escorting my child off site to a safe location if required etc. *

YesNo

*If you tick ‘No’, you must remain on-site for the duration of all sessions.

I consent to receiving confidential information, such as reports, via email* *

YesNo

*Email is not “guaranteed” to be secure

I understand that Life Skills Hub clinicians do not undertake family assessments or complete reports for the purpose of family law matters. If you require a family assessment please speak with your clinician about an external referral. *

YesNo

For clients under the age of 18; I acknowledge my young person's right to privacy will be upheld by clinicians and where reasonable to do so, information may be kept private within the course of service delivery.

YesNo

Signatures

Client

Name

Signature

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Date

Client Parent/Guardian 1

Name

Signature

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Date

Client Parent/Guardian 2

Name

Signature

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Date