Testing referral form Client DetailsName *Surname *Client Address *Client Email Address *Client Contact Number *DOB *Next of kin & contact info: *Reasons of ReferralReasons of referral *Functional AssessmentEquipment PrescriptionOngoing TherapyHome AssessmentHome ModificationsSocial Work ServicesOngoing Therapy - Proposed frequency and mode of delivery (Final scheduling will be determined by OT clinical judgement):Choose one of the following:FortnightlyMonthlyOther (please provide detail)Ongoing Therapy - OtherSocial Work ServicesSocial Work Services - Proposed frequency and mode of delivery (Final scheduling will be determined by OT clinical judgement):Choose one of the following:FortnightlyMonthlyOther (please provide detail)Social Work Services - OtherReferrer DetailsName *Surname *Phone *Organisation *Email *Date of Referral *Client consent for referralClient Consent for referral *YesNoDoes this person have an Enduring Power of Attorney (EPOA)? *YesNoYesNDIS Participant InformationNumber *Plan Dates *Is your NDIS Plan separated into multiple funding periods? *YesNoFunding Period #1 — (Please confirm adequate funding is available prior to submitting referral): *Funding Period #2Funding Period #3Funding Period #4Plan *Choose one of the following:NDIS plan-managedNDIS self-managedNon-NDIS (Private Client)NDIA ManagedPlease include Plan Manager contact details *Plan GoalsPrimary Diagnosis / Disability and reason for referral *Gender *MaleFemaleNon-binaryPrefer not to sayTransgender (please specify if comfortable):Prefer to self-describeTransgenderGender - Prefer to self-describeCurrent medical conditions *Current services in place *Lives with *Lives aloneLives with FamilyOtherLives with other *Safety IssuesFor the safety of our staff, please outline if there are any safety considerations to be aware of when visiting the client at home.Is the person currently treated involuntarily under the Mental Health Act? *YesNoUnsurePlease choose one of the following:Treatment Authority (TA)Treatment Support Order (TSO)Forensic OrderUnsureDoes the person have a history of suicide attempts or self harm? *YesNoYes *Does the person present with a history of violent or aggressive behaviour toward others? *YesNoYes *Are there currently any domestic violence orders in place? *YesNoYes *Is anyone at the property known to be aggressive or violent? *YesNoYes *Does anyone at the property currently present with, or have a history of alcohol or illicit drug dependence? *YesNoSelectAlcohol useCannabis UseMethamphetamine use (‘Ice’)Heroin or other opioid useUse of injecting equipment (e.g., needles, syringes)Volatile substance use (e.g., inhalants, aerosol cans)Other substance useYes *Does the participant have a Personal Safety Plan? *YesNoYes *Is there a Positive Behaviour Support Plan in place? *YesNoYes *Are there any known triggers that may cause the participant to experience emotional distress? *YesNoYes *Are there firearms in the home? *YesNoYes *Does anyone at the property have an infectious disease? *YesNoYes *Are you aware of any pets or animals on the premises? *YesNoYes *Are there any other factors relating to the safety of our therapists entering the property? *YesNoYes *Additional notes or commentsSignature *Signature:Your browser does not support e-Signature field.Send Appointment RequestSave as DraftPlease do not fill in this field.
