Test Referrall Form

Your Details

What is your name?*

What is your phone number?*

What is your email address?*

What is your relationship to the client?*

Caregiver

I am a self referring client

Other

Do you live with the client?*

Yes

Please provide the details of your relationship with the client.*

Caregiver Details

Does the client have a caregiver?*

Yes

What is the caregiver's name?*

What is the caregiver’s relationship to the client?*

Does the caregiver live with the client?*

Yes

What is the caregiver's email address?*

What is the caregiver's phone number?*

Client Details

What is the client’s name?*

What is the client's gender?

Preferred Pronouns?*

Other Preferred Pronoun?

Please detail the client's relevant medical history.*

Are there any 'Medical Alerts'? (e.g. allergies, aggressive or violent behaviour and vulnerabilities).*

Does the client identify as Aboriginal?*

Yes

Prefer Not to Say

Does the client identify as Torres Strait Islander?*

Yes

Prefer Not to Say

Does the client identify as being Culturally and Linguistically Diverse?*

Yes

We acknowledge that Australia is made up of a culturally and linguistically diverse population and we are committed to respecting the individual needs of our clients. Is there anything you would like us to know?*

What language other than English is spoken at home?*

Will an interpreter be required?*

Yes

What is the client’s street address?*

Does the client have a postal address that differs from their street address?*

Yes

What is the client’s postal address?*

What is the client’s date of birth?*

Hidden

Client Age

Hidden

Is there a shared parenting arrangement in place? If yes, please provide a copy of the relevant paperwork.

Yes

Is there a shared parenting arrangement in place? If yes, please provide a copy of the relevant paperwork.*

Yes

What is the client's phone number?*

What is the client's email address?*

Does the client attend School/Kindergarten/Childcare?*

Yes

What is the name of the client’s School/Kindergarten/Childcare?*

What is the phone number of the client’s School/Kindergarten/Childcare?*

What year level is the client in currently?*

What is the name of the client’s current teacher at School/Kindergarten/Childcare?*

What is the teacher's email address (if known)?

Who is the client’s GP?*

What is the name of the GP's Clinic?*

Are there other service providers involved in the client’s care?*

Yes

Please provide the details of the other service providers involved in the client’s care.

Please detail what tasks the client currently finds challenging / reason for the referral.*

Funding Source

National Disability Insurance Scheme

Will Occupational Therapy be funded by NDIS?*

Yes

NDIS Funded Plan:*

The following file types are allowed: jpg, jpeg, gif, png, pdf, Max. file size: 128 MB.

Please attach a copy of the NDIS funded plan OR if keeping private, please attach a copy of the client’s goals and the Support Category/Support Item the funding is coming from. The following file types are allowed: jpg, jpeg, gif, png, pdf

Are the Support Category Occupational Therapy services coming from Agency Managed, Self Managed or Plan Managed?*

Agency Managed

Self Managed

Plan Managed

Plan Manager

What is the Plan Manager's name?*

What is the Plan Manager’s email address?*

What is the client's NDIS number?*

What is the client's NDIS funded plan end date?*

What is the client's local NDIS office?*

Support Coordinator

Does the client have a Support Coordinator?*

Yes

What is the Support Coordinator’s name?*

What is the Support Coordinator’s company?*

What is the Support Coordinator’s email address?*

Veteran's Affairs

Do you have a DVA card?*

Yes

Note for DVA Client:

If you are DVA client please contact your GP to obtain a D904 form which is required for your referral.

Is it a Gold or White Card?*

Gold

White

What is the DVA card number?*

Private Health

Will Occupational Therapy services be claimed on your Private Health?*

Yes

What is the name of your Private Health Fund?*

What is your Private Health Fund membership number?*

Medicare Referral

Have you been provided with a Medicare Referral?*

Yes

Please attach the referral. The following file types are allowed: jpg, jpeg, gif, png, pdf

The following file types are allowed: jpg, jpeg, gif, png, pdf, Max. file size: 128 MB.

Package of Care

Is the client on a package of care?*

Yes

Note for Self-Referring Client:

Your package provider must agree to this referral for funds to be used. Please ask them to contact our office or complete this form on your behalf.

Which company is the package provider?*

Who is the Care Coordinator?*

What is the Care Coordinator's Email Address?

What is the Care Coordinator's phone number?

Workcover Claim

Is this a Workcover Claim?*

Yes

What is the Workcover claim number?*

Where would you like invoices to be sent?*

Final Details

Please provide any extra relevant information (inpatient/public/private hospital/discharge date etc).*

How did you hear of us?

Agreement and Document Authority

Is the client able to understand and sign agreements and other documents on their own behalf?*

Yes

What is the name of the person able to legally act on behalf of the client and sign agreements and other documents?*

Please attach evidence such as an Advanced Care Directive, etc, as applicable. The following file types are allowed: jpg, jpeg, gif, png, pdf

The following file types are allowed: jpg, jpeg, gif, png, pdf, Max. file size: 128 MB.

What is the document authority's email address?*

What is the document authority's phone number?*

This field is for validation purposes and should be left unchanged.

Referral Form

Your Details

Caregiver Details

Client Details

Funding Source

National Disability Insurance Scheme

Plan Manager

Support Coordinator

Veteran's Affairs

Note for DVA Client:

Private Health

Medicare Referral

Package of Care

Note for Self-Referring Client:

Workcover Claim

Final Details

Agreement and Document Authority