Phone: 02 44216013

Email: admin@shoalhavenoccupationaltherapy.com.au

www.shoalhavenoccupationaltherapy.com.au

PO Box 2034 Bomaderry NSW 2541

ABN: 98 649 815 001

NDIS Provider Number: 4-IRYERDE

Referral Form

If you need help filling in this form please call our office on 02 4421 6013

Please note – all new clients will be placed on a waiting list. One of our therapists will review your referral within 2 weeks. We recommend you review our group programs that are available to be booked online.

Book a group session

I understand this referral will be placed on a waiting list. *

FUNDING OPTIONS

There are many funding options available for occupational therapy services. 

If you have any questions regarding funding options, please contact our office on (02) 4421 6013 before submitting a referral.

Location *

IllawarraShoalhaven (North)Shoalhaven (South)

Shoalhaven Services:

• Aged Care

• Paediatrics

• DVA

• NDIS

• Mental Health/Counselling (Teens and Adults)

• Speech Pathology

Illawarra Services:

• Aged Care

• Mental Health/NDIS (Teens and Adults) 

• Paediatrics

Occupational Therapy Required *

YesNo

Speech Pathology Required *

YesNo

Funding to be used *

NDIS - Plan managedNDIS - Self managedNDIA ManagedPrivateThird party funding i.e. DCJAged CareDVA

Shoalhaven OT can only accept NDIA managed clients over 7 years old. Plan or Self Managed we can accept any age.

Private/Medicare clients will be requested to pay the full cost of the appointment when booking in. 

Please note: a service agreement will be issued and is required to be signed before services can commence.

The initial service agreement will cover the following:

• Occupational Therapist review of referral
  

• Speech Pathology review of referral
  

• Intake appointment

• Initial Assessment with Occupational Therapist (and allied health assistant for paediatric participants)

• Treatment plan

• Planning and goal alignment appointment

A long-term service agreement will be issued following the treatment plan.

I understand a service agreement will be issued and will outline the cost of services.  *

I agree that a cancelation fee may be charged if less that two clear business days notice is not given to cancel or reschedule an appointment. *

Do you have the client's permission to make this referral *

YesNoSelf Referral (including parent/guardian)

Referrers Name

Referrers Phone Number

Referrers Email

Clients Details

TitleMrMrsMissMsDrMaster

First Name *

Last Name *

Date of Birth *

Gender

MaleFemaleOther

Pronouns

Do you identify as Aboriginal or Torres Strait Islander?

YesNoPrefer not to say

Do you require an interpreter?

YesNo

Language for interpreter?

Please list names of authorised advocates/carers

Are there any other cultural/religious details we need to consider?

Contact Details

Home Address *

Postal address is the same as Home address

YesNo

City *

State *NSWQLDACTVICWASANTTAS

Post Code *

Postal Address

Phone Number *

Email Address

Preferred Contact

EmailHome PhoneMobile

What supports are required from Shoalhaven Occupational Therapy? *

Functional Capacity AssessmentMinor Home ModificationsOccupational Therapy ReportAssistive Technology/ Equipment Prescription Individual TherapyPaediatrics

Other?

NDIS/Aged Care Details

NDIS/Aged Care Number

Plan TypePlan ManagedSelf Managed

NDIS Plan Start Date

NDIS Plan End Date

---

Plan Managers Name

Plan Managers Phone Number

Plan Managers Email

Email for invoices

---

Support Coordinators Name

Support Coordinator's Company

Support Coordinators Phone Number

Support Coordinators Email

---

Local Area Coordinator Name

Local Area Coordinator Company

Local Area Coordinator Phone Number

Local Area Coordinator Email

Medicare Number

ACAT Assessment Details

Copy of ACAT Assessment

Browse

NDIS plan

Copy of NDIS plan

Browse

NDIS goals

Medical History

Please List Medical/Disability History *

Other medical issues

SpeechHearingVision

Do you/the client have a current pressure ulcer or is at risk of pressure ulcers? *

YesNoNot Sure

Does your/the client’s medical conditions impact on ability to manage daily activities? *

YesNoNot Sure

Have you/the client had a recent change in the ability to manage at home? Such as accessing bathroom, mobility or exiting the home? *

YesNoNot Sure

Do you/the client have a palliative diagnosis? *

YesNoNot Sure

Has the client had one or more falls in the past 4 weeks? *

YesNoNot Sure

Are there any urgent swallowing concerns? *

YesNoNot Sure

Are there consistent behaviours of concern? *

YesNoNot Sure

Are you/the client meeting communication milestones? *

YesNoNot Sure

Detail communication concerns if relevant:

Are you/the client non or minimally verbal? *

YesNoNot Sure

Are you/the client consistently difficult to understand? *

YesNoNot Sure

Do you/the client have concerns for reading and writing? *

YesNoNot Sure

Comments

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GP Name

GP Practice

GP Phone Number

GP Email

GP Medical History

Browse

Please upload medical history from GP or request a copy be sent to admin@shoalhavenoccupationaltherapy.com.au

Paediatric Client's

This referral is for a Paediatric client *

YesNo

Parents/carer's name

Does the child have difficulty with any of the following:

Self-CareGross MotorPlayEducationSocialisingBehaviour/ Emotional RegulationFine Motor

Other details

Support Services

Please list support services (including contact details)

Does the client have adequate support services/carer supports involved?

YesNo

Occupational Health and Safety Issues

Select any that apply

SmokingDrugsDangerous AnimalsViolence/Aggression Fire ArmsRemote Location No Phone Signal

More details/other issues

Please include any other relevant information relating to the referral

How did you hear about usWebsiteSocial mediaService providerWord of mouthOther (insert below)

Referral details

 

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