Explore OT Referral Form

Are you wanting to explore what Occupational Therapy could look like for you or someone you support?

Our 'Explore OT' blocks are an opportunity to explore what OT could look like for you, as part of a shorter, targeted block of support.

Each block consists of 6 hours of support including:

5x 1 hour face to face sessions (in clinic, at home or via telehealth) with an occupational therapist
1x 1 hour summary report

Explore OT is the ideal service for you to:

Understand what OT is and what it could look like for you
Be supported to set OT goals for therapy or goals to support access to NDIS
Learn more about Autism and neurodiversity
Access take-home strategies and activities to support progress towards goals at home
Receive professional recommendations for future therapy, equipment and resources

To access a block of support, please fill out the below form. If you would like any assistance with completing this form, please contact our Client Relationship Team on 8379 6976.

Referrer Information

Name of individual completing referral form *

Relationship to client (e.g. self, parent, support coordinator, etc.) *

Email address *

Client Information

Client name *

Preferred Name (if different)

Date of Birth *

Pronoun

he/himshe/herthey/themother

terminology preference

autistic/autistic personperson with autismperson on the spectrum/autism spectrumOther

please specify *

Diagnosis, medical conditions and/or allergies *

Primary contact Phone number *

Primary contact email address *

Primary contact name (if different from client) *

Does the client/care team require an interpreter? *

YesNo

If yes, which language?

Booking Preferences

Upon receipt of the completed referral form, unless we need to discuss any of your responses with you first, our Client Relationship Team will develop a Service Agreement for you based on the answers you provide. These are blocks of 6 hours of occupational therapy support. The agreement will be sent for your approval, and once approved you will be ready to be offered a suitable vacancy when it arises.

Please provide the below information to assist us in creating your agreement.

Will you be using NDIS funding or paying Fee for Service (out of pocket)? Please note: unfortunately, Autism SA does not provide Medicare services . *

NDISFFS

If NDIS, how much funding are you able to allocate for this service? *

Please upload your NDIS plan here

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NDIS Number *

NDIS Plan Start Date

NDIS Plan End Date

My Improved Daily Living (CB Daily Activities) budget is: *

Self-ManagedPlan-ManagedAgency-Managed

Plan Manager name *

Plan Manager email address *

Location Preferences (select all that apply)

Home Suburb *

School/Kindy Name *

Day Options (Name and Location) *

If other, please detail *

Day and Time Preferences (click 'add another preference' to add multiple days and times)

Please Note: Autism SA only provides weekly blocks of therapy support.

Occupational Therapy Support Type

Please only select up to 3 of the below support areas

What support are you requesting during Explore OT? *

Support to understand what OT is and what areas could be targetedDevelop OT goals for therapy or NDISLearn more about autism and neurodiversityAccess take home strategies and activities to work on goal at homeReceive recommendations for future OT blocks of support

Has the individual received OT support within the past 12 months?

Yes - a report can be providedYes - a report is unable to be providedNo

Please upload any previous OT assessments or progress reports below:

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Background Information

Please provide the following background information regarding the individual seeking to access Occupational Therapy services.

Please describe the individuals current living situation: (e.g. lives independently, lives with others, lives with family and level of support provided) *

How does the individual currently communicate? *

High-level language use and is age-appropriateSpoken language (phrases and sentences)Spoken language but with limited ability to use language functionally to get needs metNon-speakingUses gestures/body language to communicateUses visuals or other AAC

If the individual uses AAC please detail which system they use: *

Please specify:

If recieving Occupational Therapy services currently, please provide details below:

Occupational Therapist name:

Provider/Agency:

Does the client display behaviours of concern? (Please note: this is to allow us to best allocate and support the individual within Occupational Therapy) *

NoYes

Does the individual have a current Positive Behaviour Support Plan? *

NoYes

Please provide a copy of the plan

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Please specify other:

Do any of the following apply to the client?

Under Guardianship of the MinisterFoster family/alternative care arrangementCourt orderVoluntary out of home care / supported independent living2:1 support requirement

Any other information that you would like to attach:

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Any other information you would like to provide:

Explore OT Referral Form

Referrer Information

Client Information

Booking Preferences

Occupational Therapy Support Type

Background Information

Please provide the following background information regarding the individual seeking to access Occupational Therapy services.

Thank you for completing this referral form to support in the allocation of Occupational Therapy Services.