Tasmania residents, please use the link below:

https://ohs.snapforms.com.au/form/tas-comprehensive-referral-form

Referrer Information

Your First Name *

Your Last Name *

Your Email *

Your Contact Number *

Company/Organisation Name *

Participant Details

Client First Name *

Client Last Name *

DOB *

Clients Gender

Phone Number *

Email Address *

Address

Street addressStreet address line 2

City

State

Postcode

Country

NDIS Plan Number *

Accepted Diagnosis

NDIS Plan Start Date *

NDIS Plan End Date *

Is this a PACE plan

YesNoUnsure

Name of Plan Management Company (If Applicable)

Plan Manager Email (If Applicable)

Support Coordinator Name (if different to referrer

Support Coordinator Phone:

Support Coordinator Email:

Important information you would like to share

To help us best support you, please upload a copy of your NDIS plan where possible

Browse

Parent/Guardian Contact details (If appicable)

Parent/Guardian Name

Phone Number

Relationship to Participant

Does the particiant wish to sign in clinic?
If this box is not ticked, the Service Agreement wil be sent electronically.

Location of services

Please select your preferred location *

Where would you like your supports to be delivered?

In ClinicHomeSchoolTelehealthOther

Services

Occupational Therapy

Speech Therapy

Positive Behaviour Support

Physiotherapy

Exercise Physiology

Hydrotherapy

Podiatry

Dietetics

Early Childhood Supports

Occupational Therapy Assessment

Speech Pathology Assessment

Other

Functional Capacity Assessment In Clinic = $2715.86Functional Capacity Assessment External = $2909.85Specialist Disability Accommodation Assessment (SDA) = $4267.78Assistive Technology = $1939.90Supported Independent Living Assessment = $4655.76Manual Handling = $3879.80Home Modification Assessement=variable

Communication Assessment - Comprehensive = $2748.17Communication Assessment - Basic = $2133.89Communication Assessment - Screening = $1551.92Diagnostic Dyslexia Assessment = $3297.83Swallowing & MTMP Assessment -Comprehensive = $2909.85Swallowing & MTMP Assessment - Basic = $2521.87Swallowing & MTMP Assessment - Screening = $1551.92

Please provide additional information if needed

Occupational Therapy

How much funding would you like to allocate to Occupational Therapy? (Please specify funds for Assessment and ongoing Therapy)

Select a funding category for Occupational Therapy

Improved Daily Living (CB Daily Activities)Daily Activities (CORE)

How is your Occupational Therapy funding Managed?

Agency ManagedPlan ManagedSelf Managed

Speech Pathology

How much funding would you like to allocate to Speech Pathology? (Please specify funds for Assessment and ongoing Therapy)

Select a funding category for Speech Pathology

Improved Daily Living (CB Daily Activities)Daily Activities (CORE)

How is your Speech Pathology Funding Managed?

Agency ManagedPlan ManagedSelf Managed

Positive Behaviour Support

How much funding would you like to allocate to Positive Behaviour Support? (Please specify as much information as you like below)

Select a funding category for Positive Behavior Support

Improved Daily Living (CB Daily Activities)Improved RelationshipsBehaviour Supports

How is your PBS Funding Managed?

Agency ManagedPlan ManagedSelf Managed

Physiotherapy

How much funding would you like to allocate to Physiotherapy?

Select a funding category for Physiotherapy

Improved Daily Living (CB Daily Activities)Health and WellbeingDaily Activities (CORE)

How is your Physiotherapy Funding managed?

Agency ManagedPlan ManagedSelf Managed

Exercise Physiology

How much funding would you like to allocate to Exercise Physiology?

Select a funding category for Exercise Physiology

Improved Daily Living (CB Daily Activities)Health and WellbeingDaily Activities (CORE)

How is your Exercise Physiology Funding Managed?

Agency ManagedPlan ManagedSelf Managed

Podiatry

How much funding would you like to allocate to Podiatry?

Select a funding category for Podiatry

Improved Daily Living (CB Daily Activities)Health and WellbeingDaily Activities (CORE)

How is your Podiatry Funding Managed?

Agency ManagedPlan ManagedSelf Managed

Dietetics

How much funding would you like to allocate to Dietetics?

Select a funding category for Dietetics

Improved Daily Living (CB Daily Activities)Health and WellbeingDaily Activities (CORE)

How is your dietetics Funding Managed?

Agency ManagedPlan ManagedSelf Managed

Early Childhood Supports

How much funding would you like to allocate to Early Childhood Supports?

Select a funding category for ECI

Improved Daily Living (CB Daily Activities)Daily Activities (CORE)

How is your ECI Funding Managed?

Agency ManagedPlan ManagedSelf Managed

Funding Periods (if applicable)

If your plan has funding periods, please add details below

Who will be signing the Service Agreement?

Who is able to sign the service agreement for services/ and for funding use?

ParticipantOther (e.g. parents, legal guardian, Public Guardian)

Please Specify

Will they be present at time of the initial appointment?

YesNo

Clinical Information

Please attach any supporting reports?

Browse

Are there other Allied Health Professionals involved in the participants care?

YesNo

Please list details

If the individual or family is of non-English speaking background, do they require an interpreter?

YesNo

If yes, what language?

Form of communication

VerbalBody GesturesSign LanguageCommunication Devices

Mobility status

IndependentAssistive (e.g. Wheelchair)Dependent with CarerWalking AidOther

Please provide further details

Does the participant have any challenging behaviours?

YesNo

If yes, please provide further details

If yes, is there a behaviour support plan in place? [Please attach a copy]

YesNo

Please upload a copy of Behaviour Support Plan

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Please provide the name and contact details for the Behavioural Support Practitioner ?

Does the participant have any Sensory issues?

YesNo

Please review list and check that you have completed all details/ provided supporting documentation before submitting referral

NDIS accepted disability/ies or conditions specifiedCopy of Plan OR snips included (goals and funds available relevant to referral)Plan dates confirmedManagement of Plan details providedRisk Assessment completed in fullCopy of Behavioural Support Plan attached (where relevant)Details of relevant support people included Copies of any recent reports relevant to the referral attached.

Please note Optimum will not place Participant on referral/ waitlist until all necessary detail and supporting documentation is received.

Form Type

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