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Referrals

Our new and improved online Referral Form (below) is the easiest way to begin your journey with us.

If you need any assistance with filling out a Referral Form, we are available to help during AEST Business Hours on 03 9087 1000.

Personal Details

First Name *

Last Name *

Phone Number *

Email Address

Date of Birth *

Gender

Address

Street *

Suburb *

State *

Post Code *

Living ArrangementAloneFamily / PartnerSupported AccommodationOther

If Other, Please Specify

Support Person

Support Person NameOptional

Support Person Phone NumberOptional

Relationship

Translator Required?YesNo

Preferred Language?

Is the person a recipient of NDIS funding? *

NDIS Number *0 / 9

NDIS Plan Date (From) *

NDIS Plan Date (To) *

Please upload NDIS Plan Details

No file chosen

Background & Services

What is the person's diagnosis / NDIS-accepted condition? *

Further details

Please select the Service(s) required:Assistive TechnologyDriving SchoolErgonomic AssessmentFalls Prevention EducationFunctional Capacity AssessmentHome ModificationsHome Safety AssessmentIndependent Living Options (ILO)Life Skills TrainingMedico-legal Assessment & Report WritingMental Health Support ServicesPaediatricsPain ManagementSensory AssessmentSDASILSDA & SIL CombinedSOS Approach to Feeding (Bendigo only)

Please select preferred Driving School locationMoonee PondsBendigoMornington Peninsula

Driving School: Please select current licence statusWish to Obtain Learners PermitCurrently Holds Learners PermitCurrently Holds Probationary LicenceCurrently Holds Full LicenceThis information is needed when you select Driving School as a required service.

Driving School: Learners Permit: Do you have an X-condition?YesNo

Driving School: Learners Permit: How many hours of supervised driving have you completed?

Drivers Licence Number *

Drivers Licence Expiry *

Has a VicRoads Medical Report been completed in the last 6 months?YesNo

Driving School: Have any of your driving lessons been funded by the NDIS?YesNo

Driving School: Transmission TypeManualAutomatic

Is the participant taking any medication?YesNo

If yes, please provide medication details.

Preferred Delivery MethodIn PersonTelehealthSelect multiple if required.

Total Support Hours CalculatedThis is based on the Services you have selected. Please contact us after submitting if further hours are required.

Are You Referring Yourself?

Referrer Details

First Name

Last Name

Phone Number

Email Address *

Job Title / RoleSupport CoordinatorCase ManagerLocal Area CoordinatorCarer / Other

Relationship *

Name of Organisation

ABN

Street Address

Apartment, suite, etc (optional)

Suburb

State

Post Code

Bill-To Details

Total Support Hours CalculatedThis is based on the Services you have selected. Please contact us after submitting if further hours are required.

Funding TypeIf Plan Managed, or Self Managed please provide details:

The OT Group will seek payment via:the Participant.This is calculated based on the "Funding Type" selected.

The OT Group will seek payment via:the Plan Manager.This is calculated based on the "Funding Type" selected.

The OT Group will seek payment via:the NDIS directly.This is calculated based on the "Funding Type" selected.

The OT Group will seek payment via:privately.This is calculated based on not being an NDIS participant.

Name of Organisation

First Name

Last Name

Phone Number

Email Address *

In-Home Risk Assessment

Please tick below to Indicate acknowledgment or issue.Is there a history of violence?Is there a history of alcohol or drug abuse?Are there firearms at the residence?Do any pets or livestock require restraining?Does anybody at the house have an infectious disease?Is the residence isolated or without mobile coverage?

Authorise and Complete Referral

Print Name

Today's Date *

Declaration *I declare that all information is correct and truthful

Use information in Service Agreement? *I wish for the information supplied to be used to fill in the OT Group Service AgreementNo

Signature of Participant or Participant's Representative *

Sign here

Signature of Authorised Representative of Client Representative

Sign here

How'd you hear about us?GPSupport CoordinatorAllied HealthOT Australia WebsiteGoogleSocial MediaFamily or FriendOther

Details

Opt in to our newsletter? *YesNo

Please upload Supporting Documents or NDIS Plan Details (if applicable).

No file chosen

Funding Calculation

Locations

Servicing Australia-wide via Telehealth Services. Occupational Therapy Practices in Melbourne and Bendigo VIC.

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