You can always press Enter⏎ to continue
Welcome
Welcome
We believe in collaboration and that no one provider has all the answers. That is why we have created this form to link us with your providers. This will ultimately give you, the participant, a better whole experience 
Connect a Provider Form
  • 1
    Press
    Enter
  • 2

    Unfortunately, this service is only for Determined2 participants. Thanks

    Press
    Enter
  • 3
    Press
    Enter
  • 4

    With your permission we can link Determined2 with your other providers making collaboration easier. For example, they can receive a copy of your support plan, session feedback and session notes. 

    In most cases this will give your chosen provider the opportunity to know more about your time with us, give recommendations on how we can best assist you and additionally share any information about the services they provide for you with Determined2.

    To complete this form you will require:

    • The name of the provider you wish us to connect with
    • The providers contact number 
    • The providers email address 
    Press
    Enter
  • 5
    Press
    Enter
  • 6

    Unfortunately, this service is to link Determined2 to one of your service providers. Thanks

    Press
    Enter
  • 7
    Press
    Enter
  • 8
    Business name of your GP or other allied health professional. If unknown please write UNKNOWN
    Press
    Enter
  • 9
    Your selected allied health professionals name
    Press
    Enter
  • 10
    Email of the selected provider. If unknown please write UNKNOWN
    Press
    Enter
  • 11
    If unknown please write UNKNOWN
    Press
    Enter
  • 12
    Not compulsory, if no additional information please select NEXT
    TextSizeCreated with Sketch.
    • Huge
    • Large
    • Normal
    • Small
    BoldCreated with Sketch.
    ItalicCreated with Sketch.
    UnderlineCreated with Sketch.
    Underline CopyCreated with Sketch.
    Ok
    NumberList Copy 2Created with Sketch.
    quoteCreated with Sketch.
    BreakCreated with Sketch.
    ImageCreated with Sketch.
    Ok
    SmileyCreated with Sketch.
    Press
    Enter
  • 13

    Once this form is submitted, we will send a copy of your support plan to {nameOf} for their records.
    Your support plan includes basic information about you and your needs within our service, this is usually information collected at your first session or Meet and Greet.

    We can include extra information that will give more details about you and your sessions, you can choose to add these next.
    We highly recommend choosing these extras when linking to another health service like an Occupational Therapist, Physiotherapist or Exercise Physiologist as this information will allow them to build on the work that you are doing in our service and assist them with making more detailed recommendations.

    Press
    Enter
  • 14
    Session feedback is the feedback you or your supports provide about your sessions
    Press
    Enter
  • 15
    Session notes are the detailed notes taken by the Immersion Therapy Specialist at the end of each session, they include distance travelled, duration of activity, intensity of activity and mood before and after session.
    Press
    Enter
  • 16

    Privacy and Your Information

    Determined2 is committed to protecting your privacy. We collect and handle personal information that you provide on this form to develop your personal plan.

    Determined2 will only use your information in accordance with relevant privacy and other laws. For us to provide the best possible service, we may need to share your personal information with others, we will seek your consent to do so where required.

    If you wish to contact Determined2 about the information that you provide on this form, please call 0417 932 466 or email admin@determined2.com.au

    You also have the right to access your information and seek its correction under the Freedom of Information Act 1982. For information about making a Freedom of Information (FOI) application, please contact the Office of the Australian Information Commissioner on 1300 363 992.

    If you have a complement or complaint about Determined2 please click here https://determined2.com.au/compliments_or_complaints/

    You can also give feedback to the NDIS Commission:

    They take feedback or complaints about services that you are not happy with. You can call them on: 1800 035 544

    Your Information Release

    I give consent for my information to be obtained / released as indicated above. I understand that this consent will remain valid until the expiry of my current service plan.

    I understand that my information can be shared without my consent, provided:

    It is unreasonable or impracticable to seek consent; or consent has been refused; and

    The disclosure is reasonably necessary to prevent or lessen a serious threat to the life, health or safety of a person or group of people

    Press
    Enter
  • 17
    Pick a Date
    Press
    Enter
  • 18

    If you would like to connect more than 1 provider please submit an individual 'Connect a Provider' form for each provider (for example; if you would like to connect 3 providers, fill out this form 3 times for each individual provider).

    Press
    Enter
  • 19
    Sign here to give consent for Determined2 to share your selected information with your nominated provider
    Clear
    Press
    Enter
  • Should be Empty:
Question Label
1 of 19See AllGo Back
close
Save & Continue Later

Your form is saved successfully!

If you want to continue answering your form later, please enter the email address you would like to send the link to:

Please enter a valid email address.

Something went wrong while saving your answers. Please try again.

Email has been sent successfully.

Save your progress

OR
Already have an account? LOGIN
Skip Create an Account

Save your progress

Terms of ServicePrivacy Policy

Your form submission has been saved as a draft.

If you want to continue answering your form later, please enter the email address you would like to send the link to:

Save your progress

OR
Forgot Password?

Your form submission has been saved as a draft.

We’ve sent you an email with a link to complete your submission.

Logout