New Referral Form

New Referral Form

Please note, the more information you provide on this form, the quicker we are able to process your referral and allocate you a therapist.
Please note * indicates mandatory fields, this form will not submit if all mandatory fields are not complete.
CLIENT DETAILS
Legal name*

First NameLast Name
Preferred name
Date of Birth*

DayMonthYear
Date
Address*

Street Address

Street Address Line 2

SuburbState

Post Code
Please select the Team (location) you would like to refer to*
BALLARAT - Not currently accepting Speech Pathology and Occupational Therapy referrals - for any further queries please call Allied Therapy Services on (03) 4311 1400.
BENDIGO - Not currently accepting Occupational Therapy referrals - for any further queries please call Allied Therapy Services on (03) 4416 3000.
Email address for client communication*
example@example.com
Is this the client's personal email address?*

YesNo
If no - can this email address be used for personal client correspondence?*

YesNo
If not clients email address, please indicate person's name and relationship to client
Name
Relationship
Phone number*
Is this the client's personal phone number?*

YesNo
If not clients phone number, please indicate person's name and relationship to client
Name
Relationship
If no - who does it belong to and what is their relationship to the client?*
Emergency Contact

First NameLast Name
Relationship to client
Phone Number
Please enter a valid phone number.

REFERRAL ACCEPTANCE CRITERIA

We are a community-based therapy service, experienced in working with people aged 16+. Please tick if you meet this criteria. We can provide recommendations for services outside our expertise, please get in touch via our contact form.
Please confirm the client meets this criteria:*

Client is aged 16 or over
Client Gender*
Self described gender
Is the client of Aboriginal or Torres Strait Islander origin?
What is the clients cultural background?
What is the clients preferred spoken language?
Is the client proficient in english or is a interpreter required?

Client is proficientInterpreter required (enter language)
Language for interpreter*
Are there any cultural considerations our therapists should be aware of?
Are you / the client currently seeing any therapists from Allied Therapy Services, or are you / the client a new client?*

New clientCurrent client
How is your therapy funded?*
* Allied Therapy Services is not able to accept clients whose funding is managed by the NDIA *

	Yes or No	Comments
Do you / does the client have any known medical, psychological or behavioural conditions that may impact on safety? (Including bariatric needs).
Do you / does the client have a Positive Behavioural Support (PBS) plan in place? If so, please attach a copy below.

	Yes or No	Comments
Are there any religious or cultural considerations to be aware of?
Is there a risk of violence or aggression towards the therapist?
Does anyone in the house smoke? *Occupants are requested not to smoke during the visit.

	Yes or No	Comments
Are the house and property number visible from the street?
Is there mobile phone reception?
Are there any firearms or dangerous weapons stored on the property? *Firearms/weapons are to be locked away during visit.
Are there any animals or pets at the property? *Animals/pets are to be restrained or kept outside during the visit.
Are there any environmental hazards? E.g. hoarding, significant disrepair, poor hygiene etc.

	Yes or No	Comments
Do you / does the client have any known medical, psychological or behavioural conditions that may impact on safety? (Including bariatric needs).
Do you / does the client have a Positive Behavioural Support (PBS) plan in place? If so, please attach a copy below.

CLIENT DETAILS