OT + SP Referral

Participant’s First Name *

Participant's Last Name *

Date of Birth *

Participant's primary condition or diagnosis *

Home Address *

Suburb *

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Participant Phone (if applicable)

Participant Email (if applicable)

How would the participant like to be identified? *

He / HimShe / HerThey / ThemLet me type

Participant's Gender - please specify *

Participant's Pronouns - please specify *

Are you an NDIS participant? *

YesNo

NDIS Number *

NDIS Number Formatted

Have you been referred from *

MedicarePrivate HealthOtherNone

Medicare number *

Referral Form *

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Private Health Fund Name *

Member Number *

Any relevant information to be included on invoicing (item number, descriptions, etc)

Who should be the default point-of-contact for this referral? *

ParticipantSupport CoordinatorParent, Carer or GuardianOther

To change the default point-of-contact, please discuss this with our team after completing your referral

Please specify the default point-of-contact for this referral *

Are you... *

Self Managed (we will send an invoice directly to the family to arrange payments)Agency Managed (we will create a service booking on the MyPlace Portal, and claim invoices direct from the portal)Plan Managed (we will send all invoices to your plan manager to arrange payments)Unsure

Plan Manager Phone *

Plan Manager Email (for invoicing) *

Plan Start Date *

Plan End Date *

SUPPORT COORDINATORS

Do you have a support coordinator? *

YesNo

Support Coordinator Name(s) *

Company *

Support Coordinator Phone *

Support Coordinator Email *

Primary Contact Name *

Relationship *

Secondary Contact Name

Relationship

What service(s) do you require? *

Occupational Therapy ReportOccupational Therapy Session(s)Speech Language Therapy Session(s)Behavioural Support Session(s) or Report

Please note: We are unable to provide behavioural support to participants under 5 years old, so we may be unable to facilitate your referral request. Behavioural Support for an Early Intervention Plan must be provided by Early Years Trained Allied Health Professional.

Do you have behaviour support funding allocated in your NDIS plan? *

YesNoUnsure

What are the participant's primary goals?

Please upload any relevant participant goals documents

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Has the participant seen an Occupational Therapist or Speech Pathologist before, and are handover, reports, or supporting documents available? *

Yes, the participant has seen an OT or SP before, and document(s) ARE availableYes, the participant has seen an OT or SP before, but document(s) ARE NOT availableNo, the participant has not seen an OT or SP beforeNot relevant

How often would you like to see an occupational therapist? *

Once per weekTwo times per weekFortnightlyOther

For your OT report, what is your preferred method of service? *

Face-to-FaceTelehealth

Please specify your preferred time *

Please specify your preferred location(s) for OT sessions *

HomeSchoolClinic (Robina)Other

Please specify the name of the school or daycare *

Please specify your preferred location *

How often would you like to see a speech pathologist? *

Once per weekTwo times per weekFortnightlyOther

For your speech language therapy sessions, what is your preferred method of service? *

Face-to-FaceTelehealth

Please specify your preferred time *

Please specify your preferred location(s) for Speech sessions *

HomeSchoolClinic (Robina)Other

Please specify your preferred location *

Please specify the name of the school or daycare *

Years of Study *

Teacher *

School Contact *

Please specify which OT report you need by selecting below *

Functional Capacity AssessmentSupported Independent Living AssessmentAssistive Technology AssessmentIndividualised Living OptionsSpecialised Disability AccomodationSensory ProfileUnsure, I would like a therapist to call me to discussNot relevant

Please specify what equipment is needed *

Please specify which behavioural report is required *

Interim Behavioural Support Plan (IBSP)Functional Behaviour Assessment (FBA)Functional Behaviour Assessment (FBA) & Comprehensive Behaviour Support Plan (CBSP)

Would you like a report following your initial assessment for speech pathology? *

Yes, we would like a report following the initial assessment for SPNo, we would not like a report following the initial assessment for SPNot relevant

An initial assessment covers their medical diagnoses/ background information, NDIS goals, SP observations, and recommendations. The initial assessment is not mandatory, but it is something we recommend

Not sure what an initial assessment is, or not seen a therapist before? Click here

What are the behaviours of concern? *

Are there any restrictive practices? (Eg. anything that is used to control the participant’s behaviour - medication, equipment, locks, etc) *

YesNoNot SureOther

List any current professionals or therapists also providing services to the participant

What risks may be present throughout any session(s)? (participant temper/mood, dangerous equipment, environmental factors, etc)? *

Is there any additional information you'd like to share?

Please upload any relevant documents (allied health reports, additional supporting information, etc)

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Information collected in this form will be used to create your profile within our secure systems.
We may use this information for contact purposes. This information is collected in accordance with our Privacy Policy .

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PARTICIPANT DETAILS

PLAN DETAILS

SUPPORT COORDINATORS

SUPPORT CONTACTS

HOW WE CAN HELP

SESSIONS

REPORTS

OTHER INFORMATION