It's A Practise Referral Form V2

Referral Form
Thank you for choosing us as your provider for Occupational Therapy services. Please read below carefully before proceeding.
Referral forms become legal documentation on a person's file.

As the nature of healthcare referrals is often foreign to new clients or participants (e.g. referrals are generally completed by your GP or other Allied Health Professional), when it comes to declaring details for exactly who is completing this referral form, you must read this information carefully to ensure you understand how to fill out the form correctly.

You can come back to this information at any time whilst completing the form by selecting 'back' at the bottom of the form.

1. The first question asks you to declare if the person completing the form fits into one of the following two options:
1. Self-Referrer: This option is relevant if the person completing the form (i.e. entering all the details) is the Client/Participant.
2. Other Referrer: This option is relevant for any person other than the Client/Participant who may be assisting the Client/Participant by entering the details into the form with or without them present/by their side. They may or may not also be the Primary Contact.
2. If the person completing this form is not the Client/Participant
- They must select the Other Referrer option. It is false and misleading to select the Self-Referrer option if you are assisting a person by completing the form on their behalf.
- If this is a Self-Referral, you can proceed to start completing the form, as the below information is related to collecting details for a Primary Contact, and as a Self-Referrer, you are effectively the Primary Contact.
3. As an Other Referrer, you will be asked if you are also the Primary Contact.

The Primary Contact is the legal parent/guardian/nominee. For example, if not an appointed family member, it is usually a Support Coordinator or Case Manager.

If you select yes, the listed form fields will request your contact details.

If you select no, further fields to provide contact details for the Primary Contact will be made available.

For example, this option would apply if you are a GP, Allied Health Professional, Support Worker, family member or friend who has stepped in and is helping out by completing the referral form, but you are not the Client/Participant's nominated and official contact person to discuss or coordinate appointments or complete confidential paperwork on their behalf.

Due to privacy, as if you are not the Primary Contact, we cannot contact you to coordinate our services or commence the intake process. Contact by It's A Practise in response to a referral can only be made directly with the Client/Participant or their nominated/officially appointed Primary Contact, therefore you need to include those details in the section that will be made available when you select no, when asked if you are the Primary Contact. If we determine during the intake process that this information has not been provided, a new referral will need to be completed.

We hope this helps and please get in touch if you have any difficulty or any questions: hello@itsapractise.com.au or 0493 590 019.

Declaration 1: Is the person completing this form a Self-Referrer or Other Referrer?

Client/Participant Personal Information

Sensitive information such as precise address and DOB is not collected in this form.
Preferred Title*
E.g. Mx, Miss, Ms, Mrs, Mr, Master.
Client/Participant Full Name
Pronouns
Age (years and months)*
E.g. 29 and 8 months
Suburb and State that the Client/Participant lives in
Please ensure this is the exact suburb name as this impacts our scope to travel. Full address will be requested in a secure form once the referral has been considered and if proceeding.
Client/Participant Contact Phone Number
Mobile or Landline - ensure to state area code if providing a landline and leave spaces with the format as follows: 0000 000 000
Client/Participant Email Address*
example@example.com
Client/Participant best contact time/availability and any other relevant information with regards to contact*
Must be between our business hours of Tuesday-Friday, 9:00am - 4:00pm. State N/A if further details are to be provided for an alternative (Primary) contact.
Referrer Contact Information
Is the Referrer also the Primary Contact?
Referrer's Full Name*
Full name of Organisation the Referrer works for/represents*
State N/A if not applicable
Please state your relationship to the Client/Participant*
E.g. LAC, Support Coordinator, Mother, Primary Carer, GP, Physio, Support Coordinator, Insurance Company Case Manager, Neighbour etc
Suburb and State that the Referrer is based in
Referrer Phone Number*
Mobile or Landline - ensure to state area code if providing a landline.
Referrer Email Address*
example@example.com
Referrer best contact time/availability and any other relevant information with regards to contact.*
Must be between our business hours of Tuesday-Friday, 9:00am - 4:00pm. State N/A if further details are to be provided for an alternative (Primary) contact.
Primary Contact Details
Primary Contact Full Name
Full name of Organisation the Primary Contact works for/represents
State N/A if the Primary Contact is a family member etc
Please state your relationship to the Client/Participant*
E.g. LAC, Support Coordinator, Mother, Primary Carer, GP, Physio, Support Coordinator, Insurance Company Case Manager, Neighbour etc
Suburb and State that the Primary Contact is based in
Primary Contact Phone Number*
Mobile or Landline - ensure to state area code if providing a landline.
Primary Contact Email Address*
example@example.com
Primary Contact best contact time/availability any other relevant information with regards to contact.*
Must be between our business hours of Tuesday-Friday, 9:00am - 4:00pm. State N/A if further details are to be provided for an alternative (Primary) contact.

Reason for Occupational Therapy & Medical Information

This is preliminary information to ensure we are able to understand your needs.
Communication needs: please select all that apply:

Vision ImpairmentHearing ImpairmentCulturally and Linguistically Diverse (CALD) and requires a translatorNone of the aboveOther
Please state the language for the Translator
Diagnosis'*
Please list the diagnosis that is impacting the person seeking services.
What are your main concerns for seeking Occupational Therapy? *
Please describe what barriers you are currently experiencing and/or areas you would like the assessment to address.
In addition to the previous question, do you have any specific Referral Goals?*
State any goals and/or what you would like to achieve from this OT referral.
Please provide any information relating to any hospitalisations and/or falls without hospitalisation in the past 12 months.
Approximate dates and reasons for hospitalisation and/or approximate dates for all falls that did not result in hospitalisation in the past 12 months.

Declaration & Consent
I, the Referrer (Self-Referrer or Other Referrer stated below), confirm that all information in this form is true and correct to the best of my knowledge.

I understand that withholding or providing misleading information regarding the nature of the referral may impact its outcome and could lead to the discontinuation of services.

In accordance with It's A Practise's Privacy & Information Management Policy & Procedure, by submitting this form I consent to the collection of information for the purposes of considering the referral for Occupational Therapy services further.

You can withdraw your consent at any time by contacting us at hello@itsapractise.com.au or 0493 590 019.
Today's Date*

DayMonthYear
Full Name of the Person Who Completed This Form*
Confirm if the person named above is a Self-Referrer or Other Referrer*
Confirm name of Organisation*
State N/A if not applicable.
Please provide the email address to send the automated confirmation and copy of the Referral.*
example@example.com
Should be Empty:

Referral Form

Thank you for choosing us as your provider for Occupational Therapy services. Please read below carefully before proceeding.

Client/Participant Personal Information

Referrer Contact Information

Primary Contact Details

Method of Service Delivery

Confirmation of Pre-Requisites for Telehealth (Terms of Use)

Clients/Participants who are not Independent with video calls

Services Required & Funding Category

NDIS Approved Participants

Reason for Occupational Therapy & Medical Information

How did you hear about us?

Declaration & Consent