NDIS PARTICIPANT REFERRAL FORM

Thank you for your referral to Occupational Therapy Consultancy. To ensure we provide an optimal service and an appropriate Occupational Therapist to meet your needs, please complete the following form in as much detail as possible. If you would like to attach a copy of your plan, this will expedite your referral enquiry.
Participant Details
Name
Date of Birth
Address
Phone
Email
NDIS Funded Condition
Co-occurring condition/s (if applicable)
NDIS Plan Details
NDIS Participant Number
Referrer Details
Name
Organisation and Contact Details
SelfFamilyCase ManagerSupport Co-ordinatorLocal Area Co-ordinatorOther
Phone
Email
Reason for referral (current service remit)

Functional Capacity Assessment and ReportClinical InterventionSensory Profile AssessmentOther
Payments
NDIS standard hourly rate $193.99

Please note, by submitting this referral you acknowledge that cancellations with less than 24 hours notice are charged the full rate
How many hours do you require
Billed under Improved Daily Living

Unfortunately we are not currently accepting referrals for NDIA managed clients
Who is responsible for payment

NDISPlanManagerSelf
Details for billing (if plan managed)
Details for billing (if self managed)
Any other information you think we should know?
NDIS Plan

Cancelof
Please press submit or alternatively, return this form via email lindsey@otconsult.au
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