Mealtime Therapy Referral Form

Please complete this document when referring for Mealtime services.

Mealtime therapy is designed to support autistic individuals who have a range of mealtime challenges. It considers the impact different factors may be having on an individual’s eating and drinking, and develops and implements appropriate personalised therapies to address them. Our team are occupational therapists and speech pathologists who focus on identifying and individual’s desires, setting goals and supporting a person to achieve these goals to enhance quality of life.

Mealtime therapy at Autism SA is offered as individual (1:1) therapy, in pairs or in small groups.

Completion of this referral form allows for allocation of the most appropriate mealtime therapy service for the individual based on their identified needs and past mealtime assessment and/or support.

MEALTIME REFERRAL DETAILS

Has the person received any mealtime assessments previously? *

NoYes

Please upload a copy of the individual's mealtime assessment report (please note: this is required to be eligible for Autism SA mealtime therapy services) *

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Does the client have a current or previous Oral Eating and Drinking Care Plan (OEDCP) or Mealtime Support Plan (MSP)? *

NoYes

If yes, please provide a copy: *

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Does the individual experience ongoing coughing, choking, gagging or vomiting when eating or drinking? *

YesNo

Does any of the below occur for the individual during or after mealtimes? Please select all that apply. *

CoughingChoking (full blockage where the individual cannot breathe and requires adult intervention to clear)GaggingNone of the above

How frequently does coughing or gagging occur?

DailyWeeklyMonthlyOther

How frequently does choking occur?

DailyWeeklyMonthlyLess Frequently than Monthly

Does the individual currently tube fed or history of being tube fed (nasogastric tube or gastrostomy)? *

Yes - currently tube fedYes - previously tube fedNo - never been tube fed

Is ther any other further information you would like to provide or if any of the individuals mealtime support needs have changed:

Based on the information you have provided above, Autism SA is currently unable to provide mealtime therapy support. If you have not had a mealtime assessment before, please visit our website (autismsa.org.au) complete a referral form for a mealtime assessment.

If you have any questions or concerns regarding mealtime support, please contact the Client Relationships Team on 8379 6976 or via contactus@autismsa.org.au.

CLIENT DETAILS

Client name *

Preferred name (if different)

Client date of birth *

Pronoun

he/himshe/herthey/themother

Diagnosis (please put 'none' if there is no diagnosis) *

Medical conditions/allergies (if any)

Will you be using NDIS funding or paying Fee for Service (out of pocket)? *

NDISFee for service (out of pocket)

Please upload your NDIS Plan here *

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NDIS number: *

NDIS Plan start date *

NDIS Plan end date *

Plan Nominee (responsible person for making decisions about NDIS services on the behalf of the individual)

My Improved Daily Living *

Self-ManagedPlan-ManagedAgency-Managed

Plan Manager Name *

Plan Manager email address *

Is this a PACE Plan?

YesNo Unsure

Does the client/care team require an interpreter? *

YesNo

If yes, which language?

Other/further information

How does the individual currently communicate? *

Spoken language (phrases and sentences) Spoken language but with limited ability to use language functionally to get needs metNon-speakingUses gestures/ body language to communicate Uses visuals or other AAC

Please detail which AAC system is used:

Other/further information

REFERRAL INFORMATION

Name of individual completing referral form *

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

Email *

Phone Number *

BEHAVIOUR SUPPORT

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

Yes No

If yes, please upload Positive Behaviour Support plan

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Please specify:

MEALTIME SERVICE BOOKING PREFERENCES

At time of completing this form my preferences are (tick all that apply):

Specify home suburb

School name

Kindy name

Day Options name/location

If other, please detail:

Time preferences (please select all that apply) *

Any time Specific time/s

Specify time/s

Any other information you would like to provide?

Thank you for completeing the referral form. Please review your answers and click submit.