Referral and Enquiry Form

Is the referrer or client completing this form? *

ReferrerClient

Date of Referral *

Is this a capacity enquiry? *

Client Details

First Name *

Last Name *

Date of Birth *

Known As

Phone NumberIf client does not have a phone number please enter '0'

Email Address

Gender *

MaleFemaleOther

Funding *

PrivateNDIS

Street Address *

City *

State *

Postcode *

Client Representative Details/Emergency Contact (If Applicable)

The client does not have an emergency contact to provide.

First Name

Last Name

Phone Number

Email Address

Relationship to Client

Referrer Details

Referrer First Name *

Referrer Surname *

Referrer Phone Number *

Referrer Email Address *

Company Name

Role

The person being referred has given consent to this referral and consents to these details being kept on a cloud based client management system *

Funding Details

Requested hours for OT *Leave blank if unsure

Private Invoicing Email Address *

NDIS Details

Requested hours available for OT *Leave blank if unsure

Plan *

Plan Managed Self Managed

Funding Category *

CB Daily - Improved Daily LivingCORE - Assistance with Daily Life

Approval for CORE *Please provide proof of approval of billing from CORE

NDIS No. *

Plan Manager Name *

Plan Start Date *

Plan End Date *

Invoicing Email Address *Plan management invoicing email address

Invoicing email address *Self managed invoicing email address if different from Client's in above section

Reason for Referral

Primary Diagnosis as recognised by the NDIS/Specialists *

Reason For Referral/Relevant Medical Information *

*Important (please read): in order for Integrate OT to gather a full understanding of the participants needs/requirements, we will require a copy of the participants NDIS plan. The goals will assist us greatly prior to the initial appointment, so that we can arrive prepared and informed.

If the Client consents, please upload a copy of the NDIS Plan if able

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Any other reports or documents that may assist with services for the Client

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If your referral is accepted:

Who do we send the Service Agreement to? *

Who is the best contact for arranging appointments? *

How would they prefer to be contacted? *

How would you like the Service Agreement sent? *

Capacity Enquiry

Please describe the situation which has prompted your enquiry *

Primary Diagnosis as recognised by the NDIS/Specialists *

Please provide an ideal time frame *

Enquirer First Name *

Enquirer Last Name *

Enquirer Phone Number *

Email Address *

Director Review of Capacity Enquiry

This client is suitable for referral? (choose one) *

Yes - send this referral form back to the enquirer.No - send polite decline. An apology for lack of capacity will be sent to the enquirer.Needs liaising with enquirer.

Thank you - this Referral form will be sent back to the Enquirer

Thank you - an apology for lack of capacity will be sent to the Enquirer

Capacity notes to enquirer if required:

Director Review of Referral

This Client is suitable for services *

YesNoRequire further info

Client specified hours available

Hours for Service Agreement with Travel *

Please describe what further info is required from referrer *

Reason for declining services *

Admin Setup

Next steps for admin:

Setup client profile on SploseAdd NDIS plan expiry reminder to Splose calendarAdd budget case to SploseTurn 'on' the case alert in Splose when creating a case (choose 2 months & 70%, Mykaela)Add client to Asana project Create & send Service Agreement (once SA is returned signed, save to Splose)

SA (Paper Copy)

Download PDF copy of SA and send to Mykaela via email & upload to Asana

Service Agreement link

Hours for Service Agreement

Please send Service Agreement to:

Save and Complete Later