Occupational Therapy Referral

NDIS Participant Details

Name(Required)
MM slash DD slash YYYY
Gender (required)(Required)
Address
Interpreter (required)(Required)

NDIS Plan and Goals

Plan or goals attached (required)(Required)
MM slash DD slash YYYY
MM slash DD slash YYYY
Improved daily living (required)(Required)

Best contact person for appointments (if not NDIS participant)

Name

Person Referring

Self-referring
Name

Occupational Therapy

Reason for Referral

Which support best describes the support you (or your client)require?

Occupational Therapy Assessments (Initial/Functional Assessment)

Equipment/Assistive Technology

Hidden
Low complexity (includes minor modifications)
Additional items + 6 hours
Hidden
Complex (high cost and AT assessment report required)
Example
- Customised manual wheelchair with/without postural supports and/or pressure care cushion
- Power wheelchair with complex postural supports (includes MAT evaluation)

Ongoing Therapy Services

Housing Assessments

SDA or SIL Assessment and Report

Manual Handling Risk Assessment/Procedures

Manual handling risk assessment with plan and procedures

How is the plan managed?

How is the plan managed?
Managed by the NDIS (a service booking for the hours will be put into the portal – funds will not be accessed until services are provided)
Plan Managed
Name of the plan manager

Self Managed

Who is responsible for the account:
Name