Admission Form

At Advance Rehab Centre we make it easy for you to request our specialist rehab services. Please fill in the details in the form below to get started. If you have any questions along the way, please contact our friendly referrals team for assistance on 9906 7777 or email us at referrals@archealth.com.au

What is your name? *

What is your relationship to the client? *

Organisation or business name

CLIENT DETAILS

First Name *

Middle name (if relevant)

Last Name *

Preferred Name

Date of Birth *

I am a returning client *

YesNo

Mobile Phone *

Preferred method of communication

EmailSMSMobile phoneHome phone

Email *

Address *

Which pronouns do you use?

He/him/hisShe/her/hersThey/them/theirsOther

English is a Second Language

YesNo

ATSI

AboriginalTorres Strait IslanderNone of the Above

REASON FOR REFERRAL

Diagnosis for which treatment is being sought? *

What are the main difficulties which you are seeking help for?

What is your preferred location for therapy? *

Hurstville ClinicArtarmon ClinicsAt homeUnsure

MEDICAL HISTORY

Please highlight any known risks that therapists need to be aware of including behaviours - physical or environmental. Please state what measures are in place to manage these risks. *

NEXT OF KIN CONTACT DETAILS

Preferred method of contact

EmailSMSMobile phoneHome phone

Next of Kin/Guardian - Name *

Next of Kin/Guardian phone number *

Next of Kin/guardian - Email

Emergency Contact *

NOK/GuardianSupport CoordinatorOther (please fill in details below)

Emergency Contact Full Name

Emergency Contact Phone Number *

Emergency Contact Relationship to client

OTHER CONTACT DETAILS

GP/SPECIALIST

GP's Name

Practice Name & Suburb

Specialist's Name

Practice Name & Suburb

FUNDING TYPE

Rehab Readiness *

I am ready to proceedI am wanting more information

How will you be funding your rehab with us? *

Privately Funding NDIS CTP/LTCS/iCareAged Care Funding

What information can we provide to assist you further? *

PRIVATE FEES & TERMS

Private Price & Payment Information 2025

Therapy will be charged at the following rates for private clients:

Physiotherapy - $241
Occupational Therapy - $241
Exercise Physiology - $197
Therapy Assistant L2 - $101
Travel charges will apply for out of clinic sessions

NDIS FUNDING

In order to help you best achieve your goals and plan your treatment efficiently, it is helpful to know the following details:

What type of funding do you have?

NDIS Agency ManagedNDIS Plan ManagedNDIS Self Managed

NDIS Number

Funding available.

Date of plan end

Support Providers

Name of Support Coordinator

Company Name

Support Coordinator Phone number

Support Coordinator email

Name of Plan Manager

Company Name

Plan Manager Phone Number

Plan Manager Email

CASE MANAGER

Claim number

Name of case manager

Case Manager email *

CANCELLATION POLICY

Cancellation Policy

At Advance Rehab Centre PTY LTD we value consistent and high quality intervention. For this reason we may apply a cancellation charge for any short notice sessions made within 48 hours of appointment.

Where possible, your allocated therapy time will be used by your therapist to deliver any telehealth (where appropriate) or non-face-to-face clinical services as outlined in your treatment plan.

I have read and understand the cancellation policy *

PRIVACY & MEDIA CONSENT

Privacy Policy

Upon submitting the form, your personal details will be sent securely to Advance Rehab Centre. Please review and accept the privacy policy of Advance Rehab Centre and click I reviewed and I accept.

I have read and understand the privacy policy *

Media consent

During your rehabilitation sessions, your therapist may need to take photographs or video footage for rehabilitation purposes, including the use of external prescription exercise program website/Apps. This will not be used for, or shared with anyone other than yourself beyond your rehab session without your formal consent. If you do not want your photo or video taken in sessions please let your therapist know.

I consent I do not consent

How did you hear about us? *

Word of Mouth (Friend/Family)GPNeurologist/SpecialistNDIS Support CoordinatorHospital/Allied Health ProfessionalSocial Media (Facebook/Instagram/LinkedIn)Internet search Returning client (> 6 months since your last visit)Association (Parkinson's NSW, MS PLUS, Synapse etc)

Name of the referrer *

Thank you for completing this form. If you are happy with the information contained in this form and would like to proceed, please click the submit button below. Our referrals team will be in touch within the next 24 hour business day.

Save and Complete Later