Declaration of Income Form

This form is to determine the fee level you are required to pay for our services.

If you have a health care card or pension card, you do not need to complete this form.

Please bring your cards to your first appointment so we can charge the lowest fees possible.

Why we need to know

This information is to help the Australian Government in planning services.
All of the information you provide is confidential.
Your name will not be provided to the Government with your information.

Your full name *

Email Address

Contact phone number *

Address

Street address

City

State

Postcode

Because you said you have a Pension card

You do not need to complete this form. Please bring your Pension card to your first appointment so we can add the details to our records.

Because you said you have a Health Care card

You do not need to complete this form. Please bring your Health Care card to your first appointment so we can add the details to our records.

Your situation *

I live aloneI am a solo parent or carerI am in a couple

How many dependent children do you have?

Your income *

Timeframe *

Your Yearly Income is

Your combined income *

Timeframe *

Your Yearly Income is

We deduct $6206.00 per dependent child

Deduction for dependent children

Annual Income calculation

Annual income calculation

Annual Income calculation

Expected fees

We calculate fees based on Government guides for Community health services

LOW FEE

You are eligible for the Low fee

If you have a Health Care Card or Pensioner Card Charge
Are Single with before tax income of $39,089
Are a couple with before tax income of $59,802
Are a Family with one child before tax income of $66,009

MEDIUM FEE

Single > $39,089 – $86,208
Couple > $59,802 - $115,245
Family > $66,009 - $118,546

HIGH FEE

Single > $86,208
Couple > $115,245
Family with one child before tax income of > $118,546

Service	Low Income/ Health Care Card	Medium Income	High Income
Counselling - Adult & Families	No charge - Free	No charge - Free	$50.95 per half hour
Women’s Services – Pap smears	No charge - Free	No charge - Free	No charge - Free
Community Health Nursing	$10.30	$15.60	$50.95 per half hour
Audiology	$10.30	$15.60	$50.95 per half hour
Adult Physio	$10.30	$15.60	$50.95 per half hour
Podiatry	$10.30	$15.60	$50.95 per half hour
Dietetics	$10.30	$15.60	$50.95 per half hour
DNE	$10.30	$15.60	$50.95 per half hour
Occupational Therapy (OT)	$10.30	$15.60	$50.95 per half hour
Adult Speech Pathology	$10.30	$15.60	$50.95 per half hour
Children’s Services 0 - 18 yrs Development Psychology Speech Pathology Podiatry Occupational Therapy Audiology Dietetics	If the Child or parent holds a Healthcare Card or deemed low income No Charge	$15.60	$50.95 per half hour
Child Health Team Groups	$7.90 No charge with Healthcare Card or Concession	$7.90 No charge with Healthcare Card or Concession	$7.90
Groups	$7.90	$7.90	$7.90

I agree that this information can be used to set fees for the service/s I receive.
I acknowledge that fees I am charged may be reviewed from time to time. *

Sign here *

Clear

Declaration of Income Form

Why we need to know

Because you said you have a Pension card

Because you said you have a Health Care card

Expected fees

Service

Low Income/ Health Care Card

Medium Income

High Income