All Walks of Life Referral Form

Referral Form

What LGA does the participant currently reside in? PLEASE NOTE: not all addresses in listed LGA's are in our service area. If unsure or if other is selected, please contact our office before continuing the referral to discuss additional travel time charges and requirements before making referral *

Is the participant within a 30km radius of our office base of Emerald Vic *

YesNo

Would the participant be willing to undertake telehealth only appointments only or attend in office appointments if further than 30km from our office base in Emerald VIC *

YesNo

Participant Details

First Name *

Last Name *

Date of Birth: *

Address: *

City/ Town *

Ph. number *

Email Address *

We often send important communications via phone/ text or email. If participant does not have phone or email please type details of person to be contacted

Please note that All Walks of Life provides services to participants aged from 14 years up. If you are referring a person aged under 14, please contact our service to discuss whether our service is the most appropriate for the participant's needs before completing this referral form.

What is the participant's primary disability and presenting issues requiring Occupational Therapy support? e.g Physical disability, psychosocial disability, neurodivergence *

Please list any other known disabilities or health conditions relevant to the Occupational Therapy service request

Does the Participant identify as Aboriginal or Torres Strait Islander? *

Country of Birth *

Participant's preferred language *

Is an interpreter required *

YesNo

If an interpreter is required, which language

Does the participant have a support coordinator? *

YesNoN/A

S/C Full Name

Contact number

e-mail contact

Participant Representative/ Nominee

If this form includes a Participant Representative the below section MUST BE fully completed.

Does this participant have a representative/

YesNo

Representative First Name:

Representative Last Name

Relationship to Participant

Who is the primary person to be contacted. *

ParticipantNominee (details listed above)ReferrerOther

Ph number *

Email address. *

Additional info

Consent to electronic communications regarding appointments/ other relevant information *

Yes No

Preferred method of electronic communication *

SMSEmail

Participant Funding Information

Does the participant have an NDIS plan *

YesNo

Funding Details *

NDIS Number (if relevant)

Plan Start Date

Plan Expiry Date

Participant's Fund Management Details *

Name of Plan Manager

Contact number (if applicable)

Email

Referrer Information

Who is making this referral? *

Organisation ReferralSelf ReferralOther

Referrer's Name *

Phone number *

Email address *

Where did you hear about our organisation? *

Additional Contact Information

This includes any specialists, GP's, Care Teams, Allied Health services etc that are relevant to the participant's service provision.

First Name:

Surname:

Role

First Name:

Surname

Role:

If more space is required, please enter further contact details below including full name and role

Key Referral Information

If the plan is Nominee/ Plan Managed OR Self Managed please include details of this below.

Any requested information provided helps to assist us in having a comprehensive understanding of the Participant's needs and hours available for service provision and planning.

Have you remembered to attach

Participant Agrees to share requested information *

A copy of the current NDIS Plan

Reports or any other documentation relevant to service planning and provision

NDIS Plan - Please provide a copy of the Participant’s NDIS plan.This allows us review the NDIS goals, plan services that align with these goals and ensure that the plan includes appropriate funding for the requested services.

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Additional Supporting Documentation

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Any additional comments

Housing Assessments

Housing assessment (20 hours) - e.g. SIL/SDA/ILO (please note, we do not undertake major home modifications assessments/recommendations)

Ageing parent/s/ primary carer/sAlternative accommodation required (current accomodation not fit for needs)Homelessness/ Imminent risk of HomelessnessCorrectional facility post release planning (include date of release if known in details box belowOther (please clarify in details box below)

Please provide as much detail as possible and any relevant documents. Please note that housing assessment referrals may receive an intake appointment within the next 30 days after referral or as soon as possible for the specific purpose of ensuring all details are known to the service before assessments are conducted. The person who undertakes your intake appointment may not be the OT who is assigned for your housing assessment. This intake appintment will be billed at the standard NDIS rate.

Details of Housing Assessment request, please include any deadlines and necessary details here.

Occupational Therapy Supports

Have you had any recent assessments (up to 1 year ago) *

YesNo

Participant Assessments *

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I have uploaded necessary assessment information

OT supports required *

Functional assessment report (10 hours)Pre-planning / plan review assessment (6 hours)Sensory assessment (6 hours)N/A - Participant requires ongoing therapy support.

If ongoing therapy support required, please specify number of hours/frequency of supports preferred: details are important as they assist us in understanding needs and types of supports required. Please list any known equipment needs below

Assistive Technology (AT) & Equipment

What is required?

Assistive TechnologyEquipmentBoth

Please provide details and specifics of the type of AT or equipment required *

Participant availability

Times

9am - 1pm1pm - 5pmAnytime during business hoursOutside business hours - these times are not always available and must be discussed and agreed upon before referral is accepted.

Telehealth Appointments

From time where face-to-face appointments may not be suitable, due to illness or for other reasons, telehealth video or phone options can be used where suitable to ensure that appointments can be delivered in a timely and efficient manner avoiding delays to services.

Your Occupational Therapist will assess and confirm whether Telehealth services are right for you.

If required would you undertake a Telehealth appointment? *

YesNo

Which telehealth option is preferred *

VideoPhoneEither

Travel Charges

Travel charges are separate to your appointment fee and are for mobile face to face services that your OT may be required to travel to.

NDIS PARTICIPANTS

The two charges that apply are the Provider Travel Time Fee and the Non-Labour Hire Charge.

Fees are charged as per the NDIS Price Guidelines and are subject to change. You can find more information on these fees at https://www.ndis.gov.au/media/7150/download?attachment

Wherever possible, we will attempt to minimise travel charges by assessing suitability, and where appropriate telehealth or in office appointments may be offered.

Please indicate below if you agree to accept that travel charges will apply in relevant circumstances.

PRIVATE CLIENTS

Private Travel Charges - For private clients travel charges will apply at the same rate of hourly services. Please note that travel charges are not covered under Medicare if acessing rebated services.

DVA CLIENTS

Travel charges may apply as per the DVA schedule for travel.

I understand and accept that travel charges may apply separate to appointment fees *

YesNo

Consent to Referral

Does the person being referred have capacity to give informed consent having had the reason for referral and documents required fully explained? *

YesNo

If no, does the client representative have relevant Permissions to consent to referral of client to ALL WALKS OF LIFE for services? *

YesNo

Please note: We understand that participants may be on the waiting list of several organisations in order to secure services quickly. In the event you no longer require our service, we ask that you advise us by phone or email so that we may remove you from our waitlist. We are unable to place referrals on hold and will need to keep working through our waitlist.

Full Name *

Authorised to give consent as *

Signature *

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Date: *

If written consent is unable to be obtained at time of submission of referral, has verbal consent been given

Name of person giving verbal consent

Consent is given by a person aged 14 and over. *

I have read, understood and agree with terms and conditions as set out by All Walks of Life. *

Are you the most appropriate person to complete our risk assessment form prior to our initial visit *

If no, please nominate who we should contact to complete this form

Does the participant/nominee agree to adhere to All Walks of Life's COVID 19 & communicable diseases screening protocol, including notifying us if there is any exposure risk or illness impacting our visits? *

I acknowledge that all information provided is accurate and complete to the best of my knowledge. I understand that acceptance of this referral is based on the details and type of service requested as outlined in the referral form. Please note that any additional requests for services not included in the original referral, or delay in the provision of requested information on the referral form may impact the indicated waitlist period or, in some cases, result in the referral being declined if additional requested services cannot be accommodated. *

Is a copy of the relevant documentation attached to the referral? *

YesNoWill be sent via text message within 48 hours Will be sent via email within 48 hours

Name *

Signature. *

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I am authorised to provide medical information documentation as: *

All Walks of Life Occupational Therapy Services

P: 0421 697 156. - E: info@allwalksoflife.com.au. - M: PO Box 470 Emerald VIC 3782. - W: www.allwalksoflife.com.au

ABN 61 356 017 309

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