Clinical and Client-Focused Procedures

Purpose

To ensure all client referrals are managed efficiently, equitably, and in alignment with Joyful Journey OT’s values and service capacity.

Scope

This procedure applies to administrative staff, clinical team members, and leadership involved in onboarding new clients.

Procedure

1. Referral Received

   • Referral is received via phone, email, or practitioner. Admin complete the referral form which, once submitted, is automatically are added to the Splose Waitlist and emailed to the Director.

   • Self-referrals via the website or forms emailed out to support coordinators automatically are added to the Splose Waitlist and are emailed to the Director.

2. Clinical Review & Triage

   • Director, Senior OT or assigned clinician reviews the referral and flags:

     • Urgency or red flags (e.g., risk of harm, complex needs).

     • Suitability for Joyful Journey’s service model.

     • Potential match to clinician availability and skillset.

   • Referral is categorised using tags on the waitlist (e.g. new-grad approved, Senior Only, NDIS, private, FCA etc.).

3. Waitlist or Intake Booking

   • If accepted:

     • Clinician is allocated.

     • Initial appointment is booked by admin.

     • Admin sends service agreement, consent form, background form, via welcome email.

   • If declined:

     • Admin provides appropriate reasoning and external referral options.

4. Handover to Clinician

   • Completed paperwork and client file are prepared on the OneDrive and Splose. All intake documents are saved to the client’s digital file (OneDrive).

   • Assigned clinician reviews paperwork and prepares Initial Session document on Splose.

Roles & Responsibilities

• Admin: Intake communication, paperwork coordination, referral tracking.

• Senior OT/Clinical Reviewer: Referral suitability review, triage decisions.

• Clinician: Service delivery begins once client is onboarded.

• Director/Practice Manager: Support for complex or declined cases.

Related Documents/Forms

• Splose Waitlist Form (saved to reception Google Chrome bookmarks)

• Service Agreement Template (Splose)

• Consent Form (Splose)

• Background Form (Splose)

• Welcome email template (Splose)

Purpose

To ensure all services are delivered under a clear, signed agreement that outlines the responsibilities of both Joyful Journey OT and the participant, in alignment with NDIS requirements.

Scope

Applies to all clients receiving NDIS-funded services and all staff involved in onboarding or reviewing agreements.

Procedure

1. Issuing Agreements

   • Admin sends a service agreement and consent form with the intake pack.

   • Admin checks consent is signed before service delivery begins. This information is found on the NDIS Tracker Spreadsheet

2. Parent/Carer Responsibility

   • Parents are informed that services are funded from their plan's total budget (Section 33) and they are responsible for managing this. This information is found on the Service Agreement.

3. Storage

   • Signed documents are saved in the client’s OneDrive file and flagged in the NDIS tracker. Signed service agreements are also emailed to plan managers by Admin upon completion for plan-managed clients.

   • Once a Service Agreement in returned, a corresponding Case is created in Splose, including plan dates, budget, assigned clinician and a case expiry alert set at 2-months prior to the end and 90% completion alert.

4. Annual Review

   • Admin monitors end dates for renewal purposes. Splose alerts clinician and admin when renewal is needed.

   • Clinician discusses goals, any changes, and confirms continued consent.

Roles & Responsibilities

• Admin: Issue, file, and track agreements, confirm consent prior to sessions.

• Clinician: Review goals.

• Parents/Guardians: Sign and return documents.

• Practice Manager: Oversight of renewals and disputes.

Related Documents/Forms

• NDIS Service Agreement (Splose)

• Consent Form (Splose)

• NDIS Tracker Spreadsheet (OneDrive)

Purpose

To ensure parents/carers remain actively involved in their child’s therapy, even when therapy is delivered within the school setting.

Scope

Applies to any clinician providing sessions in school environments.

Procedure

1. Parent Contact Requirement

   • Parents must participate in a clinic-based or phone session at least once every school holidays or once every 3 months.

   • Failure to engage may result in pausing school-based therapy for the next term.

2. Clinician Responsibility

   • Schedule regular parent contact and document in notes.

   • Raise concerns with Senior OT if contact cannot be established.

3. Admin Role

   • May follow up with parents if clinicians are unsuccessful in making contact.

   • Send reminder emails when a term is ending.

4. Escalation

   • If no contact occurs after two reminders, notify Practice Manager for next steps.

Roles & Responsibilities

• Clinician: Schedule and document contact.

• Admin: Reminders and documentation.

• Practice Manager: Make final decisions on session pauses.

• Parent/Guardian: Attend sessions or phone calls.

Related Documents/Forms

• Parent Contact Reminder Email Template

• School-Based Session Log via Splose appointments tab

Policy Title: Parent Engagement Requirement for Ongoing School-Based Therapy

Purpose:

To ensure effective collaboration and continuity of care, parents/guardians of children receiving school-based therapy are required to participate in a minimum of one scheduled communication touchpoint (either a phone call or clinic-based meeting) at least once per school term or school holiday period (i.e., every 3 months). 

Failure to maintain this contact may result in therapy sessions being paused until meaningful engagement occurs.

The following provides further support and clarity around the School-Based Therapy Communication Procedure.

Scope:

This policy applies to all clients receiving school-based therapy services through Joyful Journey Occupational Therapy.

Parent/Guardian Expectations:

• Parents/guardians must book and attend a phone or in-clinic appointment with their child’s therapist at least once every 3 months (typically once per term or during holidays).

• This check-in allows for progress updates, goal review, and collaborative planning.

• Where a parent is unresponsive or does not book a check-in within the required period, sessions for the upcoming term may not be scheduled until engagement occurs.

Clinician Responsibilities:

• Track the last parent communication/check-in in clinical notes and flag upcoming due dates.

• Provide parents with 2 clear reminders (via email and/or clinic phone) if no check-in has occurred within 10 weeks.

• Liaise with admin to pause future session bookings if communication remains unconfirmed by week 12.

• Document all communication attempts in the client’s record.

Admin Responsibilities:

• Support therapists by tracking school-based clients who are due or overdue for check-ins using a shared spreadsheet or CRM tag.

• Send reminder emails or text messages as requested by the therapist.

• If the 3-month check-in window is missed, ensure school-based bookings are placed on hold for the following term until clinician confirms re-engagement.

Communication Scripts

Clinician – Initial Reminder Email (Week 10)

Subject: Request to Schedule Check-In for [Child's Name]

Hi [Parent's Name],

I hope you’re well. As part of our commitment to collaborative care, we ask all families receiving school-based therapy to connect with us for a quick check-in once each term or during the school holidays.

This is a chance to discuss progress, update goals, and ensure our sessions continue to align with your child’s needs.

Please contact reception at 0422 755 004 or info@jjot.com.au to book a phone or in-clinic appointment. Without this, we may not be able to continue school-based sessions into the next term.

Looking forward to connecting soon,

Admin – Follow-Up Reminder (Week 11–12)

Subject: Follow-Up: School Therapy Check-In for [Child’s Name]

Hi [Parent's Name],

We’re following up to help you book your required termly check-in with your child’s OT. This quick conversation helps us ensure therapy remains effective and family-centered.

Please call 0422 755 004 or reply to this email to book a time. If we don’t hear from you soon, we’ll need to place next term’s school sessions on hold until contact is made.

Thanks so much,

Purpose

To maintain high standards of clinical care and legal compliance through accurate, timely documentation and regular audits.

Scope

Applies to all clinicians documenting and storing client information.

Procedure

1. Documentation Expectations

   • Notes must be completed within 3 business days of a session.

   • Progress reports and NDIS reports are due 6 weeks prior to plan reviews.

2. File Storage

   • All documents are stored in the client’s OneDrive folder, under standardised headings.

3. Auditing

   • The Director selects 2–3 random clients per clinician quarterly.

   • Audit checklist used to review documentation compliance.

4. Feedback & Follow-Up

   • Findings are shared during supervision and/or quarterly performance review meetings.

   • Support is provided if compliance is not met.

Roles & Responsibilities

• Clinician: Timely and accurate documentation.

• Director: Conducts audits, provides feedback.

• Practice Manager: Supports accountability.

Related Documents/Forms

• Clinical Audit Checklist/Spreadsheet (OneDrive)

• File Naming Convention Guide (JJOT Intranet)

• Progress Note Template (Splose)

Purpose

To minimise risk to staff working alone in homes, schools, or the community.

Scope

Applies to all clinicians providing mobile services.

Procedure

1. Risk Assessment

   • A Home Visit Risk Assessment must be completed before first home visit.

2. Check-In System

   • Staff who are off-site for a full day will have a scheduled 5-minute check-in phone call with a member of leadership.

   • Staff who are more than 15 minutes late back from an off-site appointment without notice will be called by a member of leadership.

   • Instances of staff who are more than 30 minutes late back from an off-site appointment without notice will result in an emergency contact phone call and a phone call to 000.

3. Red Flags

   • Situations such as aggressive behaviour, unsecured animals, or unsafe environments must be reported to the Practice Manager.

4. Emergency Action

   • If at risk, staff should leave immediately and call 000 if needed.

   • Notify Practice Manager/Mentor as soon as possible.

Roles & Responsibilities

• Admin: Conduct risk assessment,

• Clinician: Inform leadership of late arrival as appropriate.

• Practice Manager: Escalation, risk management.

Related Documents/Forms

• Home Visit Risk Assessment Form (Splose)

Purpose

To ensure all discharges are handled professionally, with proper documentation and communication.

Scope

Applies to all clinicians and clients nearing end of service.

Procedure

1. When to Discharge

   • Achievement of goals, parent request, non-engagement, funding exhausted, or unsafe circumstances.

2. Process

   • Discuss discharge with family and document decision.

   • Complete discharge summary (if funding allows) and final note.

   • Notify admin to archive client.

3. Communication

   • Offer a closing phone call or email summary to families.

   • Update referral sources if needed.

Roles & Responsibilities

• Clinician: Initiate and complete discharge process.

• Admin: Archive records, update database.

• Practice Manager: Support with complex discharges.

Related Documents/Forms

• Discharge Summary Template (OneDrive)

• Archiving Procedure

Purpose: To outline when and how to archive client files in line with record-keeping obligations and space management.

⏳ When to Archive

• 7 years have passed since final service delivery

• Or, if the client was under 18 at time of service, archive 7 years after they turn 18

How to Archive

1. Label the folder:
   e.g., DL – Delilah Lees – 2025 (Archived 06.2032)

2. Move the folder into:
   Joyful Journey Drive > Archived Clients > [YEAR]

3. Mark as read-only

   • Right-click → Share → View only for all users

   • Remove editing access for past clinicians

4. For Splose clients: On the client’s dashboard page, select Actions: Archive and then follow the prompts

Do Not:

• Delete any archived client files

• Store archives on personal devices or USBs

Purpose

To protect children and vulnerable individuals by ensuring staff report any concerns of harm in accordance with legislation.

Scope

Applies to all staff at Joyful Journey OT.

Procedure

1. Recognise

   • Staff remain alert for signs of abuse, neglect, or harm.

2. Respond

   • Document factual observations (do not investigate).

   • If unsure, discuss with the Senior OT or Practice Manager immediately.

3. Report

   • If required, make a report to DFFH or relevant agency.

   • Inform Director if a report has been made.

4. Record

   • Complete an incident record and store confidentially.

Roles & Responsibilities

• All Staff: Observe, report, document concerns.

• Senior OT: Support decision-making.

• Practice Manager/Director: Ensure follow-up, support staff.

Related Documents/Forms

• Mandatory Reporting Flowchart (JJOT Intranet)

• Child Concern Record Template (JJOT Intranet)

• Incident Report Form (JJOT Intranet)