emma Fayelecaun. bva. mTaP. AThR

Art Therapy Registration & Service Agreement

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Client Name
This is optional if you feel relevant
Primary Contact Name
Will the client be accompanied by anyone during the session? If so who?
Is the client under 18 or do they have an intellectual disability that requires decision making support?
If yes, to see therapist unaccompanied consent is required
Recent incident or ongoing concern
History of triggers, self-harm or violence
Are you NDIS funded?
If you are NOT an NDIS participant continue down to the consent section. Art therapy is classified as: Supports category 15 – “Improved daily living/other therapy”, line item 15_610_0128_1_3.
Plan type
Name of NDIS financial manager (who to invoice)
Support Person's Name (if required)
Do you have therapeutic services for core support?
Do you have therapeutic services for capacity building support?
Could include: mental health history, significant/relevant incidents, diagnosis, preferences, triggers
Do you consent to photography…
Imagery is kept as part of reporting and only shared with permission. Tick all that apply
Do you consent to audio/video recording…
Recordings are kept as part of reporting and only shared with permission. Tick all that apply.
It is the responsibility of the client/their supports to be sure their NDIS plan is in effect and is current for the period that services are provided. If a plan has expired and the client has attended a session or sessions that falls outside their time frame, the fee for the session will be charged to the client.
Art therapy sessions are held in a private and safe space. All information is regarded as confidential, except in cases where the client has nominated others with whom they permit to share. Information may also be shared if the therapist has reason to believe that the client is at risk or that the client may be putting others at risk of harm. If the therapist deems this necessary they will discuss this with the client first.
Reports are made and stored in a clients file after each session. Reports can include session notes, quotes, audio or video recording or photographs. Reporting is used to keep a record of the clients attendance, to monitor developments in their artmaking and to track their progress over time. Reports are confidential, except where reporting information may be shared with the clients nominated people or the therapists supervisor. Reports are for the benefit of both the client and the therapist and can be requested to be viewed or discussed at anytime.
You may list up to two people. eg. carer, family member, friend. Include their relationship to you.
Consent is a major part of our session, if at anytime you feel unsure or you have a question you can request to “PAUSE”, we can take a break, reset or clarify at any time.
Associated Cost of 1:1 Creative Art Therapy sessions are charged at a competitive rate of $190 for a 1 hour session, for NDIS clients. This rate is advised by (and slightly less than) the NDIS price shedule 2020-21 and the NDIS support catalogue 20-2. For clients that are not in receipt of NDIS benefits the hourly rate is $150. This rate includes all art materials, clients personal file creation, documentation and reporting. If these costs are outside of your means please let me know and we can discuss this further.
Rescheduling or cancelling an appointment with more than 24 hours notice incurs 50% of the fee. Rescheduling or cancelling appointments with less than 24 hours notice will be charged the full fee.
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