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Allied Health – Customer Referral Form
Home
Allied Health – Customer Referral Form
Step 1 of 7
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Allied Health Referral Form
Are you referring yourself?
*
Yes, I'm referring myself
No, I'm referring someone else
Do you have access to a current NDIS plan?
*
Yes, I have access to NDIS funding
No, I do not have access to NDIS funding
How did you hear about us?
*
Google
Facebook
Event
Referral
Radio
Outdoor Billboard
Indoor Billboard
Television
Other
Referrer Details
Referrer's Name
*
First
Last
Referrer Phone
*
Referrer Email
*
Relationship to Participant
*
Parent
Support Coordinator
Caregiver
Other
Participant Details
Is the participant an existing breakthru customer?
*
No
Yes
Unsure
Please provide the participant's Visicase number (if known)
Participant's Name
*
First
Last
Participant's Postcode
*
Participant's Phone
Participant's Email
Gender
*
Male
Female
Other
Prefer not to say
Participant's Address
*
Country of Birth
*
Date of birth
*
Date Format: DD slash MM slash YYYY
Is the participant of Aboriginal or Torres Strait Islander descent?
*
No
Yes, Aboriginal
Yes, Torres Strait Islander
Yes, Both Aboriginal and Torres Strait Islander
Are there any shared care or custody arrangements?
*
No
Yes
Unsure
Primary Disability or Diagnosis
*
Not listed
Alcohol Dependency
Alzheimer's Disease
Angelman syndrome
Ankylosing spondylitis
Asperger syndrome
Autism disorder
Bipolar affective disorder
Borderline personality disorder
Cerebral palsy
Chronic lung disease
Cleft palate and lip
Coffin-Lowry syndrome
Congenital eye condition
Congenital hearing condition
Cornelia de Lange syndrome
Cri du Chat syndrome
Developmental delay
Diabetes mellitus
Down syndrome
Edwards syndrome
Epilepsy
Foetal alcohol syndrome
Fragile X syndrome
Global developmental delay
Hearing loss
Human immune deficiency virus (HIV) disease
Huntington disease
Hypoxic brain injury
Major depressive illness
Malignant neoplasm of blood or immune disease
Malignant neoplasm of brain
Microcephaly
Mild intellectual disability
Moderate intellectual disability
Motor neuron disease (also called amytrophic lateral sclerosis)
Multiple sclerosis
Multiple traumatic amputations
Muscular dystrophy
Obesity
Obsessive-compulsive disorder
Other Anxiety disorders
Other arthritis
Other chromosomal conditions not listed elsewhere, including Kabuki syndrome, Williams syndrome
Other congenital brain conditions, for example tuberous sclerosis
Other congenital conditions
Other metabolical disorders
Other Neurological
Other Neurological (List A)
Other Neurological (List C)
Other Physical
Other psychosocial disorders
Other Sensory/Speech
Other substance dependency
Other unspecified infectious diseases
Parkinson's Disease
Pervasive developmental disorder(try not to use)
Prader Willi syndrome
Profound intellectual disability
Renal failure
Rett syndrome
Rheumatoid arthritis
Schizophrenia
Severe intellectual disability
Spina bifida
Spinal cord injury (Complete)
Spinal cord injury (Incomplete)
Stroke
Systemic lupus erythematosus
Traumatic brain injury [also called head injury and acquired brain damage]
Unspecified dementia
Unspecified intellectual disability
Visual impairment (including blindness)
Please specify primary disability or diagnosis
*
What is your goal for this intervention?
*
To access the NDIS
To improve my independence in the home/community
Other
Emergency Contacts
Emergency contact person / plan nominee
*
Emergency contact number
*
Name of person signing service agreement
*
Primary Carer / Nominee Details
Primary Carer Name
*
First
Last
Primary Carer Phone
*
Primary Carer Email
*
Relationship to Participant
*
Parent
Support Coordinator
Caregiver
Other
Please specify 'Other' relationship
*
Plan Details
NDIS Number
*
Plan Start Date
Plan End Date
*
Please list 2-3 of the participant's NDIS goals
*
Primary NDIS Support Category
*
Improved Daily Living
Improved Relationships
Specialist Behaviour Intervention
Behaviour Management Plan
Core Supports
Other
Funding amount or number of service hours required
*
Which service are you enquiring about?
*
Behaviour Support
Counselling
Psychological Therapy
Occupational Therapy
Exercise Physiology
Speech Therapy
Therapy Assistant
Please select behaviour support required
*
Specialist Behaviour Intervention
Behaviour Management Plan
Please select Psychological Therapy required
*
Counselling
Cognitive Assessment
Please select the primary Occupational Therapy required
*
Functional Capacity Assessment (FCA)
Assistive Technology
Home Modification Assessment
Supported Independent Living (SIL)
Skill Building Programs
Other
Please select the primary Speech Therapy required
*
Communication
Mealtime support
Literacy support
Other
Risk Identification
Does the participant have a history of aggressive or violent behaviour toward others?
*
Yes
No
Will any other people be present at the property during the appointment?
*
Yes
No
Are there any pets at the property? (e.g. birds, cats, dogs, horses)
*
Yes
No
Is there anything we need to know for access to the property?
*
Yes
No
Is the property in a fire prone area?
*
Yes
No
Are there weapons in the property that we need to be aware of?
*
Yes
No
Will you or anyone on the property be under the influence of drugs and/or alcohol?
*
Yes
No
Is there anything else we need to be aware of that may put you or us in any type of danger?
*
Yes
No
Other Details
How is the Participant's NDIS plan managed?
Agency Managed
Plan Managed
Self Managed
Fee for Service
Other
Please specify 'Other' type of NDIS plan management
*
Invoices should be sent to
*
Contact person
*
Phone Number
*
Email
*
ABN
*
Which primary service is the participant currently accessing?
Behaviour Support
Counselling
Psychological Assessment
Occupational Therapy
Exercise Physiology
Speech Therapy
Other
None
Please upload reports of any services currently received here
Drop files here or
How urgently does the participant need support?
*
Urgently (within 1 week)
Somewhat urgently (within 2 - 3 weeks)
Non-urgent (1 month+)
Session preference
*
Face to face
breakthru Office
Home visit
Telehealth
Contact person to organise sessions
*
First
Last
Additional Information or Comments
Please list any other details such as worker preferences, diagnosis and known risk factors.
Name
This field is for validation purposes and should be left unchanged.
