Participant Intake Art Therapy Form Please select one of the following: * NDIS Participant PRIVATE Participant PRIVATE Participant under 13 years Individual Service Agreement This Participant Service Agreement outlines the therapeutic services provided by HAPPYMESS STUDIO and the obligations of the Arts Therapist and Participant. It is intended to provide information so that you feel safe and supported in your relationship with the Arts Therapist and the therapeutic process. Should you have any concerns please advise your Arts Therapist as soon as possible. This Agreement is made between: The Participant Participant Details Participant Name * First Name Last Name Participant Email * Participant Date Of Birth * MM DD YYYY Participant Contact Number/Mobile * Participant Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Gender * Female Male Transgender Non-binary Intersex Prefer not to say Pronouns She/Her He/His They/Their Other Who is responsible for the Participant? * Self Mum/Dad Grandparents Guardian Carer Friend Primary Contact Name * First Name Last Name Primary Contact relationship to Participant * Primary Contact Number/Mobile * Primary Contact Email * Primary Contact Address Address 1 Address 2 City State/Province Zip/Postal Code Country Please select your preferred method of delivery * Sessions delivered at HAPPYMESS STUDIO in Bellingen Sessions delivered at the participant location Sessions delivered Online Sessions delivered at an external location Does the participant attend school every day? * Yes No N/A If Participant attends school, please name school And HAPPYMESS STUDIO - The Provider Shop 2/41 Hyde Street Bellingen, NSW, 2454 HAPPYMESS STUDIO provides mental health support programs for all people, including neuro, physical, gender and culture diverse people. This Form is for Participants requesting Creative Arts Therapy sessions. Please complete one form per Participant. All personal information will remain confidential unless otherwise authorised by you. Mind And Emotional Wellbeing Of Participant Are you receiving any support for your mind and emotional wellbeing? Yes No If yes, do you give consent to HAPPYMESS STUDIO to communicate in your best interest? Yes No If yes, please provide details Please list any significant (positive or negative) life changes or stressful events you have experienced recently Please include any additional relevant information including the length of time this has been an issue OR what would you like to get out of your Arts Therapy sessions. Are there any known risks of concern that HAPPYMESS STUDIO should be aware of at this time? * Do you have any experience of Art Therapy or art making? Please note: Art experience or art interest is not required to participate Yes No Any other information you would like to add Service Agreement and Expectation Rights and Responsibilities Happymess Studio Agrees to: • Actively work with the Participant to identify goals and needs • Work with the Participant's Primary Contact listed in this agreement to assist the Participant exercise choice and control and have their voice heard in matters that affect them • Review the provision of supports at regular intervals with the Participant and their Primary Contact • Provide the agreed safe and high quality supports that meet the Participant's needs at the Participant's preferred location and times whenever possible • Respect and respond to the cultural values and beliefs of the Participant • Treat the Participant with courtesy and respect • Inform the Participant of all costs associated with the provision of supports including the cost associated with cancellations • Protect the Participant's privacy and confidential information as per the Privacy Act 1988 (and provide a copy of Happymess Studio Privacy policy upon request) • Store Participant information in a secure file • Inform the Participant how to make a complaint and treat them fairly and impartially if they make a complaint • Listen to the Participant's feedback and resolve problems quickly • Give the Participant a minimum 48 hours' notice (where possible) if HAPPYMESS STUDIO has to change a scheduled appointment to provide supports • Allow 4 hours of Review Report writing per annum, to be charged at service rate • Issue regular invoices for the provision of supports delivered The Participant/Participant Representative agrees to: • Keep HAPPYMESS STUDIO informed on how you wish your services/supports be delivered • Provide accurate information and keep HAPPYMESS STUDIO informed of any changes to your personal information • Ensure there are appropriate funds available for claiming services that have been booked and provided. If HAPPYMESS STUDIO is unable to make a claim to NDIA for the provision of a service due to insufficient funds, you (the Participant) are responsible for payment. (Applicable to NDIS participants only) • Treat HAPPYMESS STUDIO with courtesy and respect • Provide a safe, hygienic and smoke-free environment for HAPPYMESS STUDIO to work in • Talk to HAPPYMESS STUDIO is you have any concerns about the supports being provided • Provide a minimum of 48 hours' notice for any cancellation to HAPPYMESS STUDIO. If notice is not provided, HAPPYMESS STUDIO's Cancellation Policy will apply (see below) • Provide sufficient notice if you need to end the Service Agreement (see Ending This Service Agreement below) • Inform HAPPYMESS STUDIO immediately if your NDIS plan is suspended or replaced by a new plan or you are no longer a NDIS participant. (Applicable to NDIS participants only) • Lodge or advise HAPPYMESS STUDIO of any positive feedback or complaint if you are dissatisfied with the service or its delivery (see Complaint Policy below) • Request a copy of any of our Policies at any time • Participants or family members who are unwell MUST advise HAPPYMESS STUDIO and the Arts Therapist, giving at least 48 hours notice • Photography consent form will be discussed prior to any footage taken • Participants under the age of 18 MUST have a parent/guardian/carer present for the duration of the session • Participants over the age of 18 will be assessed case by case if additional attendance and support is required • All Outreach (we come to your location), will incur a travel cost and will calculated at approximately 30 minutes of the scheduled rate Costs Once we receive this form, we can allocate the best suited Arts Therapist to you. A team member from HAPPYMESS STUDIO assessment team will be in touch to discuss your options. Name Of Person Responsible For Payment * First Name Last Name Email of Responsible person to receive invoices Contact Number/Mobile of responsible person Cancellation Policy Cancellations are subject to the following conditions. Cancellations made within 48 hours before an appointment will be subject to a charge of 50% of the service fee. Cancellations made within 24 hours before, will incur 100% of costs. Eg: • Where Arts Therapists are unable to access the location • The participant is unavailable or have failed to be ready at the agreed place and time with no or short notice • The Arts Therapist has arrived to find unsafe conditions • The participant regularly cancels sessions If a Participant or any family member is unwell, it is your duty to notify your Arts Therapist as soon as possible. In addition, please also email HAPPYMESS STUDIO at hello@happymess.com.au Confidentiality This policy is designed to assure that information gathered by your Arts Therapist over the course of sessions is used in an appropriate and secure manner. Any information about you and / or your artwork is held with utmost confidentiality and can only be released by either your written and signed consent or by court order. Limits to Confidentiality Information may be disclosed without your consent, when; • The Arts Therapist suspects on reasonable grounds that a child or young person under the age of 18 years is at risk of physical or psychological harm or neglect • The Arts Therapist suspects on reasonable grounds that a person may seriously harm themselves or another person • Records are subpoenaed by court order • Permission is given to consult with other professionals as required, such as with your medical professional, allied health practitioner, case manager and / or psychologists • In circumstances where maintaining confidentiality presents a risk to the welfare of the HAPPYMESS STUDIO community and its staff • Disclosure is otherwise required or authorised by law Ending this Service Agreement The Participant's NDIS plan is expected to remain in effect during the period the supports are provided. The Participant/Participant's representative must immediately notify HAPPYMESS STUDIO if the Participant's NDIS plan is replaced by a new plan or the Participant stops being a Participant of the NDIS. Should either Party wish to end this Service Agreement they must give 14 days' notice in writing to hello@happymess.com.au If either Party seriously breaches this Service Agreement, the requirement of notice will be waived. Thank you, we’ve received your form and will be in touch!Visit Home Page
