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Occupational Therapy Referral

NDIS Participant Details

Name(Required)

First Name Last Name Preferred Name

Date Of Birth(Required)

MM slash DD slash YYYY

Phone(Required)

Email

Gender (required)(Required)

Male

Female

Intersex/Undetermined/Unspecified

Prefer not to state

Address

Language other than English

Alternative method of communication

Interpreter (required)(Required)

Yes

No

NDIS Plan and Goals

NDIS Number(Required)

Plan or goals attached (required)(Required)

Yes

No

Plan Start Date(Required)

MM slash DD slash YYYY

Plan End Date(Required)

MM slash DD slash YYYY

Improved daily living (required)(Required)

Yes

No

Best contact person for appointments (if not NDIS participant)

Name

Phone

Relationship

Email

Person Referring

Self-referring

If yes, do not complete the table below

Name

Relationship

Organisation

Phone

Email

Occupational Therapy

Disability/Diagnosis

Reason for Referral

What areas of support are required to assist you (your client or your loved one) to achieve NDIS goals?

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

Occupational Therapy Assessments (Initial/Functional Assessment)

Functional Assessment 4 hours (Includes: Therapy Plan)

Functional Assessment 6 hours (Includes: Summary report with therapy plan or recommendations)

Functional Assessment 10 hours (Includes: Comprehensive functional assessment report)

Equipment/Assistive Technology

Equipment/Assistive Technology Number of Hours you want to allocate

Hidden

Low complexity (includes minor modifications)

10 hours (1 item)

12 hours (1 item with report)

Additional items + 6 hours

Hidden

Complex (high cost and AT assessment report required)

16 hours

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

Weekly, fortnightly or monthly sessions with Occupational Therapist to implement interventions which target Occupational Therapy goals

Housing Assessments

SDA or SIL Assessment and Report

20 hours

Manual Handling Risk Assessment/Procedures

Manual handling risk assessment with plan and procedures

10 hours

How is the plan managed?

Plan Managed

Name of the plan manager

Email

Phone

Self Managed

How is the plan managed?

Agency Managed

Who is responsible for the account:

Participant

Other

Name

Email

Phone

Get in Touch

[email protected]
1300 190 377

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Services

Support Coordination
Specialist Support Coordination
Recovery Coaching
NDIS Counselling
Occupational Therapy

Mental Health Occupational Therapy
Paediatric Occupational Therapy
Rehabilitation Occupational Therapy
Disability Occupational Therapy

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99 654 609 006

NDIS Independent Provider Number:

4050130162

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Occupational Therapy Referral

Thank You For Your Submission