Yakini Occupational Therapy Intake/Referral Form

Name*

First NameLast Name

Date of Birth*

Date

Gender

Pronouns

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Email*

example@example.com

Country of Birth*

Primary language spoken*

Do you require a language interpreter?*

Do you identify as Aboriginal or Torres Strait Islander?*

YesNoPrefer not to say

Do you identify as Culturally and Liguistically Diverse?*

YesNoPrefer not to say

Please note any cultural needs.

Do you have a NDIS plan?*

YesNo

NDIS Number*

NDIS Plan Start Date*

Date

NDIS Plan End Date*

Date

How is the plan managed?

Plan ManagedSelf ManagedAgency Managed

Name of plan manager

First NameLast Name

Plan managers email address

example@example.com

Plan managers phone number

Please enter a valid phone number.Format: (000) 000-0000.

Formal diagnosis funded by NDIS*

Additional diagnosis

Please note any medical conditions.

How are you funded?

MedicareTACHealth FundPrivate

Preferred contact method of the participant?*

PhoneTextEmail

Contact to make appointments*

Nominee/child representative/parent to contact*

Full name

Primary contact relationship to the participant*

Primary contact phone number*

Please enter a valid phone number.Format: (000) 000-0000.

Primary contact email address*

example@example.com

Is the person making the referral the same primary contact?

yesno

Referrers Name

First NameLast Name

Referrers relationship to the participant *

Referrers phone number

Please enter a valid phone number.Format: (000) 000-0000.

Referrers email address

example@example.com

Reason for referral*

Are you wanting ongoing therapy sessions?*

YesNo, Functional Capacity Assessment only

How often would you like sessions?

Rows	Weekly	Fortnighly	Monthly
Mornings (8am - 12pm)
Mid-afternoon (1pm - 3pm)
After-School (3pm- 6pm)

In addition to 1:1 sessions, would you consider Groups?

YesNoOpen to discussion

Occupational therapy Goals*

NDIS Plan

Supports in place for the participant.

Current Therapists involved

Current medical professional engaged

Names of the medical or Allied health team indicated above

Therapy Plan Upload

Please note any presenting concerns for the participant including triggers, safety or behavioural concerns. *

Would you prefer appointments*

In personAt clinic of therapistAt SchoolTelehealth

Yakini Therapy Group's intake process for Occupational therapy is:

1- When we receive your online referral, one of allied health assistants will call you to make an initial appointment with the parent/carer/foster carer.

2- Face-to-face with parent/carer/ foster care, 45 minutes. This appointment is conducted without the child present to discuss performance issues and will help us understand your young person's needs.

3- face-to-face between the child and the Occupational Therapist, to enable the therapist to complete a standardised assessment to understand functional capacity and meet the child.

4- appointment with family (parents/foster carers/child protection services) to discuss goals of care and complete standardised assessments with the primary caregiver to develop therapy goals. At this appointment, we will discuss the therapy plan and book ongoing appointments with the OT & allied health assistant.

5- Observation of the child in another environment, preferably with peers, such as school, prep, kindergarten, sports, etc.

An occupational therapist will provide an initial report based on this intake process so you can understand what we have assessed, what we are seeing and what the plan is. Yakini OT will provide term reports based on progress, this will then contribute to your end of plan report you can use for your funding provider (NDIS/TAC/Medical team)

Times best suited for initial phone call after we recive this referral.

Rows	Monday	Tuesday	Wednesday	Thursday	Friday	Weekend
Morning
Mid-afternoon
After-School

Hours for Occupational Therapy (0-9 year olds) - 15_617_0118_1_3 Early Childhood Intervention Professional – Occupational Therapist -Vic MMM 1-5

$193.99 Per hour

Hours for Occupational Therapy (9+)- 15_617_0128_1_3 Assessment Recommendation Therapy or Training - Occupational Therapist - Vic MMM 1-5

$193.99 per hour

Who is responsible for paying the invoice?*

First NameLast Name

Phone Number of person responsible for paying the invoice?

Please enter a valid phone number.Format: (000) 000-0000.

Email for invoices to be forwarded to*

example@example.com

Name*

First NameLast Name

Signature*

Yakini Occupational Therapy Referral Form

Participant Details

NDIS Plan Details

Contacting the Participant

Referrers Details

Reason for Referral

Referral Purpose

Referral submitted by: