Far Reach Therapy Referral Form

Far Reach Therapy Referral Form

Please complete the form below - Please note Occupational Therapy is the only service provided at this time.
Participant Details
Name of Participant

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender

Other
Participant Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Name of Guardian or Family Member (if relevant)

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Who's Phone Number is this?
Email Address
example@example.com
Who's email is this?
Who is the best contact person to make the initial appointment with?

Other
NDIS Participant Number
Plan End Date

MonthDayYear
Date
How is the plan managed?
Plan Manager Name
Plan Manager Email
Please provide details of the NDIS plan funding periods (include duration of each period, funding period dates and funding allocation for Occupational Therapy services within each period)
Support Coordinator Details (If applicable)
Name

First NameLast Name
Phone
Email
Referral Details
Does the participant consent to the referrer providing this information?
What is the participant's diagnosis/es?
Reason for referral. Please provide any relevant details including presenting concerns.
Please provide NDIS goals (if known)
Does the particpant have a plan nominee?
Nominee Name
Contact Phone or Email
Attachments (NDIS Plan, Previous Reports, Letters of Support, Hospital Discharge Summary, etc)

Cancelof
Preferred appointment time
Risk screen

Please answer all required fields below to mitigate risk for client and clinician
Are there any factors limiting the participant's ability to communicate with the clinician?
Please detail...
Does the participant present with any medical risk? (i.e. risk associated with medical conditions, infectious diseases, etc)
Please detail...
Are there any cultural considerations Far Reach Therapy needs to make as part of it's service?
Please detail...
Does the participant or anyone in the home have a history of substance abuse?
Please detail...
Does the participant present with any behaviours of concern? (physical aggression, verbal aggression, property damage, sexualised behaviours, etc)
Please detail...
Are there any restrictive practices that Far Reach Therapy should be aware of?
Please detail...
Does the participant or anyone in the home have a history of criminal offences?
Please detail...
Are there any other potential risks present to the participant or clinician within the home? This includes presence of weapons, pets, property damage, other residents, neighbours, difficulty with mobile reception, any other potential risk.
Please detail...
If there is any additional important information regarding this referral that has not already been outlined, please outline it below.
Should be Empty:

Far Reach Therapy Referral Form

Participant Details

Support Coordinator Details (If applicable)

Referral Details

Risk screen