Occupational Therapy (OT) Referral Form

Occupational Therapy (OT) Referral Form
Please refer to website for health conditions that Koalified Therapy has expertise working with and primary type of OT services provided BEFORE making OT Referral

www.koalifiedtherapy.com.au
Type of OT service packages (Koala Walks) I provide:
1. Koala Hike: Short One Off Service - Initial Assessment, Equipment at Home <$1500, Education & Training for Organisations
2. Koala Climb: Therapy Sessions - Upper Limb Therapy, Cognitive Therapy, School Readiness Therapy for 3 to 6 years
3. Koala Trek: Complex Service - Wheelchair, Electric Scooter, Equipment at Home >$1500, Scooters
Koalified Therapy uses a monthly intake model (first referral in, first accepted basis) to manage demand for OT services in our Rural Outreach & Metro locations in NSW. We do not operate on a waitlist.
Date *

DayMonthYear
1. PARTICIPANT
Name*
Date of Birth*
Gender*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client phone and email*
Type 'N' if client does not have phone or email
Cultural background *
2. REASON FOR OCCUPATIONAL THERAPY (OT)
Primary Health Condition*
Initial Assessment & Summary Letter to determine OT needsWheelchair assessment, trial and prescriptionElectric scooter assessment, trial and prescriptionEquipment at Home for self-care, productive and leisure activitiesUpper limb therapyCognitive therapySchool Readiness Therapy (cognitive, fine motor, play and self care) for 3 to 6 yearsMinor home modifications (railing and threshold ramps up to 50mm height for Aged Care, Home Care & Private only)Education, Training & Resources for Organisations (e.g. schools and workplaces)
*Disclaimer: Please note exact type of OT service package (i.e. Koala Hike, Climb or Trek) is determined based on information provided in this OT referral and at discretion of Principal Occupational Therapist Indu Haridharan.
Is there more information you would like to add?*
Type 'N' if nothing to add
Face-to-faceTelehealthEither face-to-face and telehealth is suitable
Preferred days and times for assessment and/or therapy?*
3. FUNDING
Participant or Claim Number (if applicable)*
Type 'N' if private OT referral
Funding Scheme*
NDIS Plan Start Date
NDIS Plan End Date
Does the client have an NDIS plan with funding periods?*
Please ensure correct option is selected, as incorrect selection will affect payment of services and ongoing service.
Start/Finish dates for each NDIS funding period*
Type 'N' if non-NDIS referral or no NDIS funding periods allocated
Amount allocated for each NDIS funding period*
Type 'N' if non-NDIS referral or no NDIS funding periods allocated
Who is paying for the service?*
Please ensure correct option is selected, as incorrect selection will affect payment of services and ongoing service.
Who to send invoices to?*
Email
4. REFERRER
Name*
Relationship to Participant*
Phone*
Email*
Yes
Signature of Referrer*

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5. ATTACHMENTS
NDIS goals and/or planFunding provider approval for OT services (non-NDIS)Letters and/or ReportsOtherNil
File and/or Photo Upload

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Occupational Therapy (OT) Referral Form

Please refer to website for health conditions that Koalified Therapy has expertise working with and primary type of OT services provided BEFORE making OT Referral

1. PARTICIPANT

2. REASON FOR OCCUPATIONAL THERAPY (OT)

3. FUNDING

4. REFERRER

5. ATTACHMENTS