It's A Practise Referral Form

Referral Form
Mandatory Declaration
I declare that*

If I am not the participant, client or nominee/guardian, and am supporting them by assisting with completing this form on their behalf, I understand I must also provide my own details and submit/sign as the person completing the form, as I cannot complete the form or sign as though I am the participant or nominee/guardian.I am the participant or client.I am the nominee/guardian.
I declare that*

If I am not the participant or client, I understand I will be provided with the option to select who is to be contacted in relation to the referral.I am the participant or client and this does not apply to me.
I declare that*

Misrepresenting myself as the participant, client or nominee is considered a false declaration and may be treated as fraudulent, and the referral will be treated as invalid.I am the participant or client and this does not apply to me.I am the nominee/guardian and this does not apply to me.
Do you agree to this declaration?*
You will be required to provide your details in the relevant section.

Form Submitter Details
Who is completing/entering the details into this form?*

I am the NDIS participant or client.I am supporting the participant/client and/or their nominee/guardian by completing this form for them.I am the nominee/guardian.

Reason for Occupational Therapy & Medical Information
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.
Details of 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.
Is there anything else you would like to add?

Declaration & Consent
Submission of this form provides your digital signature as acknowledgement and declaration of the following:
- You acknowledge that all information provided in this referral is accurate, complete, and represents the participant/client’s circumstances truthfully.
- In accordance with the acknowlement provided in the Mandatory Declaration, this includes correctly identifying who is completing the form, who the primary contact person is, and ensuring that no information is misrepresented (e.g., a person signing as the participant/client/nominee when they are not).
- In accordance with It's A Practise's Privacy & Information Management Policy & Procedure, by submitting this form you 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.

Confirm your acknowledgement of this agreement by completing the details below and submitting the form.
Today's Date*

DayMonthYear
Confirm who completed this form *
State your Full Name*
Must match the information previously stated.
State the name of the organisation you represent (if relevant)*
N/A if not applicable
Who should we send the automated confirmation and copy of the Referral to?*
If a copy is required for both the Referrer and participant/client, we recommend providing the Referrer's email address so that they can forward their copy to the participant/client.
Should be Empty:

Referral Form

Mandatory Declaration

Form Submitter Details

Participant/Client Details

Support Person Details

Nominee/Guardian Contact Details

Primary Contact Person For The Referral

Method of Service Delivery

Telehealth Equipment & Environment Readiness

Services Required & Funding Category

NDIS Participant Information for Services

Reason for Occupational Therapy & Medical Information

How did you hear about us?

Declaration & Consent