Referral Form
Please complete the below relevant information
Name of Client
*
First Name
Last Name
Name of Guardian (If applicable)
First Name
Last Name
Client Date of Birth
*
/
Day
/
Month
Year
Date
Client Diagnosis
*
Address of Client
Street Address
Suburb
Post Code
State / Territory
Please Select
ACT
NSW
VIC
QLD
SA
NT
TAS
WA
Address of Client
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Whose email is this?
*
Please Select
Client
Case Manager
Guardian
Other
Phone Number
*
-
Area Code
Phone Number
Whose Phone number is this?
*
Please Select
Client
Case Manager
Guardian
Other
Who is best to contact to schedule the initial appointment with?
*
Client
Guardian
Case Manager
Other
Please provide contact details if different from above
Home Care Package Provider Company
*
Case Manager Name
*
First Name
Last Name
Case Manager Email
*
example@example.com
Case Manager Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Please select services you are referring for?
*
Occupational Therapy
Physiotherapy
Counselling
Speech Therapy
One of our Occupational Therapists works alongside a certified assistance dog and currently has immediate appointment availability. Please indicate the client’s preference regarding the presence of the therapy dog during appointments.
*
Please Select
Comfortable with assistance dog present
Prefer appointments without assistance dog
The assistance dog is fully trained and certified and remains under the clinician’s supervision at all times. If the client prefers appointments without the therapy dog, appointments will be scheduled based on the next available Occupational Therapist capacity.
Please select with Service Package
Comprehensive Home Safety and Functional Assessment up to 7.5 hours
Targeted Equipment Review & Recommendations up to 5 hours
Targeted Home Modification Assessment up to 7 hours
Speech Therapy Assessment (Swallowing and Mealtime) up to 4 hours
Other - Please provide information below and a quote will be provided within 24hours
Additional information regarding the referral such as equipment needing review and concerns the client is having. Please provide as much detail as possible
*
Number of Hours Approved for Services
*
Please provide total hours for Physiotherapy (Therapy sessions plus reporting)
Are home modifications required to be reviewed?
Please Select
Yes
No
Are these modifications minor or major?
Please Select
Minor
Major
Please provide more information on major modifications *Please note these involved structural changes and any permanent adaptions to the home*
Preferred Appointment Time
Please Select
Morning
Afternoon
Flexible
Can services be delivered via Telehealth?
*
Please Select
Yes
No
Additional information on the service required
*
Please confirm you have read the following regarding exclusions to the above service packages: Services do not include the sourcing or obtaining of builder or equipment quotes, liaison or meetings with builders or trades, attendance onsite during construction or installation works, or project management and installation oversight.
*
I can confirm I have read and understood the above regarding exclusions
Where unforeseen complexity arises due to the client’s presentation, environmental constraints, or clinical risk identified during assessment, additional Occupational Therapy input may be required to finalise the full scope of the service. This may include further assessment time, additional documentation, equipment trials, or onsite attendance. In such cases, a formal request outlining the rationale and additional hours required will be submitted for consideration and approval prior to any additional services being delivered.
*
I have read and understood the above statement
How did you hear about us?
Social Media
Search engine
Word of mouth
You have used our services before
Please let us know who referred you to our services, we would like to say thankyou
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