Participant Details
Client First Name
*
Client Last Name
*
Clients Date of Birth
*
Clients Gender
Male
Female
Other
Prefer not to say
Phone Number
*
Email Address
Street Address
Suburb
State
NSW
TAS
ACT
QLD
VIC
WA
NT
SA
Post Code
Country
Participants NDIS Number
Is this a PACE plan
Yes
No
Unsure
Participants NDIS Plan Start Date
Participants NDIS Plan End Date
Please upload copy of your Plan or NDIS Goals to support us in best meeting your needs.
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Alternate / Emergency Contact
Name
Phone Number
Relationship to Participant
Referral Information
Referrer's Name
Referrer's Contact Number
Referrer's Email
Referrer's Company
Location of services
Please select the clinic that is closest to you
Moonah (TAS)
Dodges Ferry (TAS)
Mornington (TAS)
Telehealth
Do you require services outside of the clinic
Yes
No
Offsite Location
Home
Other
Please provide complete address of location where services will be held
Services
Dietetics
Exercise Physiology
Occupational Therapy
Occupational Assessment
Physiotherapy
Speech Pathology
Positive Behaviour Support
Dietetics
How much funding would you like to allocate to Dietetics
@193.99 per hour
What category is your funding for Dietetics being drawn from?
Improved Daily Living (CB Daily Activities)
Health and Wellbeing
Daily Activities (CORE)
How is your Dietetics funding Managed
Agency Managed
Plan Managed
Self Managed
Exercise Physiology
How much funding would you like to allocate to Exercise Physiology
@166.99 per hour
What category is your funding for Exercise Physiology being drawn from?
Improved Daily Living (CB Daily Activities)
Health and Wellbeing
Daily Activities (CORE)
How is your Exercise Physiology funding Managed
Agency Managed
Plan Managed
Self Managed
Occupational Therapy
How much funding would you like to allocate to Occupational Therapy
@193.99 per hour
What category is your funding for Occupational Therapy being drawn from?
Improved Daily Living (CB Daily Activities)
Daily Activities (Core)
How is your Occupational Therapy funding Managed
Agency Managed
Plan Managed
Self Managed
Occupational Therapy Assessment
How much funding would you like to allocate to Occupational Therapy
@193.99 per hour
What category is your funding for Occupational Therapy Assessment being drawn from?
Improved Daily Living (CB Daily Activities)
Daily Activities (Core)
How is your funding for Occupational Therapy Assessment managed?
Agency Managed
Plan Managed
Self Managed
Physiotherapy
How much funding would you like to allocate to Physiotherapy
@224.62 per hour
What category is your funding for Physiotherapy being drawn from?
Improved Daily Living (CB Daily Activities)
Daily Activities (CORE)
How is your Physiotherapy funding Managed
Agency Managed
Plan Managed
Self Managed
Speech Pathology
How much funding would you like to allocate to Speech Pathology
@193.99 per hour
What category is your funding for Speech Therapy being drawn from?
Improved Daily Living (CB Daily Activities)
Daily Activities (Core)
How is your Speech Therapy funding Managed
Agency Managed
Plan Managed
Self Managed
Positive Behaviour Support
What category is your funding for Positive Behaviour Supports being drawn from?
Improved Daily Living (CB Daily Activities)
Improved Relationships
Behaviour Supports
How is your Positive Behaviour Supports funding Managed
Agency Managed
Plan Managed
Self Managed
How much funding would you like to allocate to Positive Behaviour Support
@193.99 per hour
How much funding would you like to allocate to Specialist Behavioural Intervention
@244.22 per hour
How much funding would you like to allocate to Behaviour Management Plan
@244.22 per hour
Behaviour Supports
@244.22 per hour
Funding to be used Flexibly
Yes
No
Please provide further information regarding your enquiry.
Plan Manager Details
Plan Manager Company
Plan Manager Phone
Plan Manager Email Address
Plan Manager Calcuation Field
Who will be signing the Service Agreement?
Who is able to sign the service agreement for services/ and for funding use?
Participant
Other (e.g. parents, legal guardian, Public Guardian)
Please Specify
Will they be present at time of the initial appointment?
Yes
No
Clinical Information
NDIS Accepted Diagnosis
Please attach any supporting reports?
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Are there other Allied Health Professionals involved in the participants care?
Yes
No
Please list details
If the individual or family is of non-English speaking background, do they require an interpreter?
Yes
No
Language/Dialect
Form of communication
Verbal
Body Gestures
Sign Language
Communication Devices
Mobility status
Independent
Assistive (e.g. Wheelchair)
Dependent with Carer
Walking Aid
Other
Please provide further details
Does the participant have any challenging behaviours?
Yes
No
If yes, please provide further details
If yes, is there a behaviour support plan in place? [Please attach a copy]
Yes
No
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?
Yes
No
Please Specify
Please review list and check that you have completed all details/ provided supporting documentation before submitting referral
NDIS accepted disability/ies or conditions specified
Copy of Plan OR snips included (goals and funds available relevant to referral)
Plan dates confirmed
Management of Plan details provided
Copy 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.
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