Tasmanian residents, please use the link below:

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

Are you completing this form for yourself? *

YesNo- Parent/GuardianNo - Referrer

Referrer Information

Your First Name *

Your Last Name *

Your Email *

Your Contact Number *

Company/Organisation Name *

Is there a Parent or Guardian?

YesNo

Participant Details

Client First Name *

Client Last Name *

DOB *

Clients Gender

Phone Number *

Email Address *

Address *

Street address *

City *

State *

Postcode *

NDIS Plan Number *

Accepted Diagnosis

NDIS Plan Start Date *

NDIS Plan End Date *

Is this a PACE plan

YesNoUnsure

Do you have a Plan Manager?

YesNoUnsure

Name of Plan Management Company

Plan Manager Email

Do you have a Support Coordinator?

YesNoUnsure

Name of Support Coordinator

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

Location of services

Please select your preferred location *

Services

Occupational Therapy

Speech Therapy

Positive Behaviour Support

Physiotherapy

Exercise Physiology

Hydrotherapy

Podiatry

Dietetics

Early Childhood Supports

Occupational Therapy Assessment

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

Speech Pathology Assessment

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

Nursing - Limited Locations Available

Nurse-Led Screening

Nursing Support Plans (For participnat's carers or Support Workers)

Support area(s):

Complex Bowel Care Support PlanPEG/PEJ Care & Enteral Nutrition (Tube Feeding) Support PlanContinence Support PlanUrinary Catheter SupportVentilatory Support (CPAP/BiPAP only)

High Intensity Skills Training

Training audience:

ParticipantFamily/CarerSupport Worker(s)

Clinical Review & Monitoring

Medication Reconciliation & Support

Direct Clinical Care

Care Needed:

Enteral feeding and medication administration (PEG, PEJ or NG)Medication administration, including subcutaneous, intravenous and intramuscular injectionsWound care and compression therapyCatheter support, including IDC and intermittent catheterisationDiabetes support, including blood glucose monitoring and insulin administration

Chronic Disease Management (Category)

Catergory

Chronic Heart Failure (also known as Congestive Cardiac Failure)Chronic Obstructive Pulmonary Disease (COPD)Diabetes

Please provide additional information regarding your nursing needs:

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?