Occupational Therapy Referral Form

Please complete this document when referring for Occupational Therapy services.

If you would like any assistance with completing this form, please contact our Client Relationship Team on 8379 6976.

Client Information

Client name *

Preferred Name (if different)

Date of Birth *

Pronoun

he/himshe/herthey/themother

Diagnosis, medical conditions and/or allergies *

please specify *

Referrer Information

Name of individual completing referral form *

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

Phone number *

Email address *

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 typically blocks of 24hrs, however, assessments alone may be less hours. 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)? *

NDISFFS

Please upload your NDIS plan here

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NDIS Number *

NDIS plan dates (start date and 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)

Occupational Therapy Support Type

What support are you requesting? *

Occupational Therapy Assessment and ReportBlock of therapy support (i.e. sessions) to learn new skills and receive supportive strategies and recommendations

Occupational Therapy Assessment and Report *

For a skill assessment (to understand the individual’s skills and support needs for motor skills, sensory processing independence skills etc)For an assessment to determine need for OT support or for NDIS plan review (funding recommendation for OT support)For a functional capacity assessment (usually for NDIS Home and Living Support e.g. SIL, SDA, ILO)Other (please specify)

Specify Other *

Block of therapy support (i.e. sessions) to learn new skills and receive supportive strategies and recommendations *

The individual has not previously received OT supportThe individual has received OT support more than 1 year agoThe individual has received OT support within the past 12 months

The individual has received OT support within the past 12 months

A report can be providedA report is unable to be provided

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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Focus Areas for Occupational Therapy Support

Please select all areas that you would like further assessed and/or supported through Occupational Therapy services.

What sensory processing and/or regulation support is required?

Social Emotional

Understanding and identifying own emotionsCoping with change/transitionsEngaging in non-preferred activitiesPlay skillsMaking and keeping friendsUnderstanding sharing and turn takingResolving conflict, winning and losing etcUnderstanding others emotions and perspectives

Further comments:

Gross Motor Skills

Mobility skills (e.g. jumping/hopping/walking/running/climbing/balance)Ball skills (e.g. throwing/catching/bouncing)Playing sportsRiding a bikeSitting upright

Further comments:

Fine Motor Skills

Further comments:

Community Access

Personal safety (e.g. road safety/stranger danger)Understanding community rules and expectationsCoping with overwhelming input within the communityAccessing community supports and programsTransportation (e.g. driving/public transportation/walking from one destination to another)

Further comments:

Other (please specify) *

Any other information you would like to provide:

Occupational Therapy Referral Form

Client Information

Referrer Information

Booking Preferences

Occupational Therapy Support Type

Background Information

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

Focus Areas for Occupational Therapy Support

Please select all areas that you would like further assessed and/or supported through Occupational Therapy services.

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