Expression of Interest - 12 week FND wellbeing program

Kokoro Mollitia

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* 1. As part of providing FND Clinical telehealth services your information will be stored and handled as per The Australian Privacy Principles [Privacy Act 1988]. Your information will remain confidential and only discussed with people whom you consent. The only time we do not need your consent to discuss your personal health information is, if there is a serious risk to yourself or others, or in the event of a legal court order being made.

Do you consent to participate in this program?

Yes

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* 2. Please provide your contact details

First Name

Last Name

Address

Address 2

City/Town

State

Postal Code

Country

Email Address

Phone Number

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* 3. What is your Date of Birth?

Date / Time

Date

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* 4. What gender do you identify with?

Male

Female

Other

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* 5. Please provide details of an Emergency contact.

Name

Relationship to you

Email Address

Phone Number

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* 6. What conditions have you been diagnosed with / Disability?

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* 7. When were you diagnosed with FND?

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* 8. Why would you like to do the 12 week group program?

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* 9. What do you hope to learn, by participating in the program?

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* 10. Are you able to commit to a 12 week wellbeing program?

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* 11. What barriers might interfere with you participating in the weekly program?

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* 12. Are there any risks of injury to yourself or others e.g. self-harm or thoughts of suicide in the past 12 months.

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* 13. Do you currently have access to technology and internet that will allow you to participate in video – conferencing / ZOOM?

Yes

Unsure

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* 14. When is the most preferred day / time for you to participate in the program?

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* 15. Are you funding the services via

NDIS Participant

Private Health Insurance [depends of relevant extras cover - please speak to your insurer]

Self Funded - I understand the fee is non refundable and will be paid in full upfront.

NSW Residents only - applying for scholarship to attend program

Other (please specify)

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* 16. If you are an NDIS Participant, is your plan

Self Managed

Plan Managed

NDIA Managed

Expression of Interest - 12 week FND wellbeing program

Kokoro Mollitia

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* 2. Please provide your contact details

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* 3. What is your Date of Birth?

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* 4. What gender do you identify with?

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* 5. Please provide details of an Emergency contact.

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* 6. What conditions have you been diagnosed with / Disability?

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* 7. When were you diagnosed with FND?

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* 8. Why would you like to do the 12 week group program?

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* 9. What do you hope to learn, by participating in the program?

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* 10. Are you able to commit to a 12 week wellbeing program?

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* 11. What barriers might interfere with you participating in the weekly program?

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* 12. Are there any risks of injury to yourself or others e.g. self-harm or thoughts of suicide in the past 12 months.

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* 13. Do you currently have access to technology and internet that will allow you to participate in video – conferencing / ZOOM?

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* 14. When is the most preferred day / time for you to participate in the program?

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* 15. Are you funding the services via

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* 16. If you are an NDIS Participant, is your plan

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* 17. If Plan Managed - [NDIS Participants] please indicate the contact details for the plan manager to send through invoices.

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* 18. For NDIS Participants, please indicate the NDIS Plan number

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* 19. For NDIS Participants, please indicate the NDIS Plan start and finish dates

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* 20. If you have any questions or comments, please document below, and we will get back to you.