Form
Referrer Details
Complete this section is you are referring someone other than yourself. If you are referring yourself, please still enter your name and email address in this section (a copy of the form will be sent to the email provided here). For the remaining questions in this section, simply write “Not Applicable” or “N/A”, then continue with the remaining sections below.
Your Name:
*
First Name
Last Name
Name of Organisation/Your Relationship to the Client:
*
Your Email:
*
example@example.com
Your Phone Number:
*
Please enter a valid Australian phone number.
How did you hear about us?
*
Client Details
Details of the person requiring the assessment service.
Name:
*
First Name
Last Name
Date of Birth:
*
-
Day
-
Month
Year
Age in Years
I.e., 5 years old
Gender:
*
Phone Number:
*
If client does not use a phone due to age or cognitive capacity, please indicate so and ensure that a guardian or representatives phone number has been included in this form.
Email:
*
If client does not use an email due to age or cognitive capacity, please indicate so and ensure that a guardian or representatives phone number has been included in this form.
Address
*
Street Address
Street Address Continued (if needed)
City, Suburb or Community
State / Territory
Postal Code
Cultural Background:
*
Primary Language:
*
Interpreter Required?
*
Please Select
Yes
No
School Name and Year Group (if applicable):
Details of Client's Next of Kin, Guardian, or Representative
If this section is not relevant, or if these details have already been provided in the 'Referrer Details' section, please answer 'Not Applicable' or 'NA' to these questions and continue with the form.
Name:
*
First Name
Last Name
Relationship to Client:
*
Phone Number:
*
Please enter a valid Australian phone number.
Email:
*
example@example.com
Details of Client's Health Condition and Services Required
Primary Disability/Health Condition:
*
Other Relevant Health Conditions (if applicable):
NDIS Number (if applicable):
*
Type NA if not applicable
NDIS Plan Dates (if applicable):
*
Type NA if not applicable
NDIS Funding Type (if applicable):
*
Please Select
Self-managed
Plan-managed
Agency/NDIA Managed (Remote OT is not a registered NDIS provider)
Not Applicable
Indicate the Number of Hours or the Dollar Amount Allocated for this Assessment:
*
Sharing your allocated hours or funding helps us understand the type of assessment you may need (e.g., succinct vs. comprehensive). Final hours and costs will always be confirmed and agreed upon together before the service begins.
Invoicing Details (email address/details of where invoices will be sent to for payment):
*
A service agreement with estimated costs will be confirmed before any services begin. Invoices will only be issued for services provided.
Please briefly describe why our services are required, including which assessment is needed (if known) and the main reasons for requesting it.
*
Any Additional Information (if applicable):
Please attach participants NDIS plan if applicable:
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Please attach medical, allied health or specialist reports that are relevant to this referral:
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Consent Form
Does the client consent to this referral?
*
Yes
No
Unable to provide consent due to age or capacity
Does the client consent to us contacting their next of kin/guardian/representative?
*
Yes
No
Unable to provide consent due to age or capacity
I understand that Remote Occupational Therapy is an assessment only service and we do not provide therapy services.
*
Yes
Please verify that you are human
*
Submit
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