About
- Meet The Team
- Our Visions & Values
Our Services
FAQ's
Client Intake Form
Contact Us

About
- Meet The Team
- Our Visions & Values
Our Services
FAQ's
Client Intake Form
Contact Us

Call 0413 482 122

Contact Our Team

Holistic Approach

Compassionate Care

Flexible Support Option

NDIS Registered

Holistic Approach

Compassionate Care

Flexible Support Option

NDIS

Registered

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A Group Of People Are Putting Their Hands Together In A Circle — Advanced Therapy Mackay In Mackay, QLD

Contact Us

T.0413 482 122

A. Office 4/44 Gordon Street, Mackay QLD 4740

Trading Hours

Mon - Fri: 8:30 am - 5:00 pm
Sat - Sun: Closed

Client Intake Form

Contact Us

Client Details

Client Details

First Name

Last Name

Date of Birth

Phone Number

Email Address

Street Address

City

State

Postcode

Client Representative Details (If Applicable)

Client Representative Details (If Applicable)

First Name

Last Name

Email Address

Phone Number

Street Address

City

State

Postcode

Field label

NDIS Details

Plan

Plan Managed

Self Managed

Agency Managed

Plan Manager Agency (If Applicable)

Agency Email Address:

NDIS Number

Funding Type

Plan Start Date

Plan Review Date

Client Goals (As stated in the NDIS plan)

Field label

Referrer Details (Person Making the Referral)

First Name

Last Name

Agency

Role

Email Address

Phone Number

Field label

I have obtained consent from the participant to make this referral and provide Advanced Therapy Mackay with the participant's personal and medical details.

Communication Needs

Communication Needs

Type

Verbal

Non-Verbal

Communication Aids Required

Other

If other provide details

Language Spoken

English

Other

Is an interpreter required?

Hearing Impaired

Language

Practitioner Preference

Practitioner Preference

Free Text

Advanced Therapy Mackay attempts to match our clients with a client preferred practitioner, although on occasion this may not be an option due to practitioner availability. Where a client is displeased with practitioner choice please take the time to discuss further by emailing mel@advancedtherapymackay.com.au

Gender of practitioner

Male

Female

Non-specific

Disability Type

Disability Type

Clients Disability Type

Field label

Restrictive Practices

Is the Client Subject to Restrictive Practices

Yes

If yes, tick below type of restrictive practice

Chemical

Mechanical

Physical Restraint

Environmental

Seclusion

Is There Approval for Restrictive Practice?

Yes

Short Term Approval

Guardian for Restrictive Practice

Field label

Reason For Referral

Referred For

Positive Behavior Support

Functional Behavior Assessment

Social Work

Psychology

Allied Health Therapy

Therapy

Cognitive Assessment

Other

How many hours required/funded?

Reason For Referral/Relevant Medical Information

Known Risk to Worker or Special Requirements.

Any Additional Information

File Upload (Please attach a copy of the current NDIS plan if possible)

Upload File

Referrers Signature

Upload File

Date

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Reach Out Today

At Advanced Therapy Mackay, we are dedicated to providing a supportive environment for our clients, where trust is the foundation and understanding is the key to our services.

We offer a comprehensive range of therapeutic assistance tailored to the needs of individuals, families, and organisations in Mackay. If you're seeking mental health support, therapeutic support services, or guidance for positive behavioural outcomes, we're here to help.

Don't hesitate to call us on 0413 482 122 and embark on a journey towards well-being.