Registration Form - Child / TeenagerPlease complete all fields below prior to your appointment. Date of enquiry * MM DD YYYY Client name * First Name Last Name DOB: Parent / Caregiver 1 * First Name Last Name Parent / Caregiver 2 First Name Last Name Mobile (primary contact) * Country (###) ### #### Email (primary contact) * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Childcare / Kindergarten / School Does your child have NDIS funding? Yes No Does your child have an EPC? Yes No Were you referred to this service? Yes No Please check to confirm you understand and agree with the service policies: Full payment for initial assessments / appointments must be received no later than 24 hours prior to the session or the session will be cancelled. For subsequent sessions, full payment must be received no later than 24 hours prior to the session or the session will be cancelled. Alternatively clients can provide credit card details via a secure link, and charged immediately after the session in accordance with the Stripe payment policy (https://stripe.com/au/privacy). All receipts will be be forwarded to the email (primary contact) once payment has been received. If payment is not received for whatever reason, future sessions will be cancelled. If clients are late for an appointment, the appointment will conclude at the time that was planned, and clients will still incur the full fee for that consultation Cancellations within 24 hours will incur a 50% cancellation fee. Signature Message for Dr Kylie Smith: Thank you!
