Private Client Referral Form

Private Client Referral Form
CLIENT DETAILS
Client's Name*

First NameLast Name
Gender*

MaleFemalePrefer not to sayNon-binary
Date of Birth*

DayMonthYear
Date
Client's Phone Number*
Please enter a valid phone number.Format: 0000 000 000.
Client's Email
example@example.com
Client's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Living Arrangements

AloneFamily / Partner (informal support)Formal Support at homeSupported AccommodationOther
Preferred Language (if English is not main language)
Translator / Interpreter or communication aids required

YesNo
If yes, please specify details of Translator / Interpreter or communication aids
CONTACT DETAILS (If different from client details)
Main Contact Name (Fill if different from Client's details)

First NameLast Name
Main Phone (if different from Client's)
Please enter a valid phone number.Format: 0000 000 000.
Main Email (if different from Client's)
example@example.com
MEDICARE and PRIVATE HEALTH

We offer fully bulk billed Medicare care plan referrals onsite at our clinic on 75 Henley Beach Road, Mile End SA 5031, by appointment only
Do you have a Medicare Chronic Care Plan referral from your General Practitioner?*

YesNo
If yes, please kindly upload your Medicare care plan / referral below:

Cancelof
Medicare Card Number - (reference number)*
Do you intend to use your private health insurance for allied health services?

YesNo
Please kindly note that we highly recommend for you to check your entitlement benefits with your private health insurer as Happy Steps is not able to claim on your behalf nor check your entitlements or out-of-pocket costs. Thank you!
REFERRAL REASON
What is your main concern for physiotherapy with us today?
Please kindly list all primary medical conditions and/or physical disabilities here
What are your expectations from therapy?
What are your goals for physiotherapy?
Type of session required

In clinic at 75 Henley Beach Road, Mile End SA 5031Home Visit (please kindly note, bulk billing is not available for this option)Telehealth
SAFETY

If you selected Home Visit, please kindly answer ALL questions in this section. If you answered "YES" to any, please kindly provide details.
Is anyone at your / client's property, known to be aggressive or violent?

YesNoUnsure
If YES, please provide details here
Does anyone at your / client's property, have a criminal history?

YesNoUnsure
If YES, please provide details here
Is there a known history of alcohol or drugs misuse at the property?

YesNoUnsure
If YES, please provide details here
Is there a known current occupant with an infectious disease (i.e. Covid, gastro, chicken pox, etc) at the property?

YesNoUnsure
If YES, please provide details here
Are you aware of any pets at the property?

YesNoUnsure
If YES, please provide details here
Please kindly include any other known factors we need to be aware of to be fully equipped for our visit:
PAYMENT of INVOICES

Invoices will be sent to the nominated person below. Please kindly note that all invoices are required to be paid in full to Happy Steps, and you can then claim any available rebates from Medicare or private health insurance (if applicable). Happy Steps is not responsible if you do not receive a rebate from Medicare or Private Health, it is your responsibility to check your rebate entitlement.
Name*

First NameLast Name
Organisation (if applicable)
Phone Number*
Please enter a valid phone number.Format: 0000 000 000.
Email*
example@example.com
Signature here
Should be Empty:

Private Client Referral Form

CLIENT DETAILS

CONTACT DETAILS (If different from client details)

MEDICARE and PRIVATE HEALTH

REFERRAL REASON

SAFETY

PAYMENT of INVOICES