Referral Form

Unfortunately Enable OT is not able to accept paediatric referrals

Date of referral *

Is this a re-referral? *

Thank you for your NEW CLIENT referral

Who is filling out this form *

Have any contact details changed for the client in the last 3 months? *

YesNo

Are there any risk changes to the environment? *

YesNo

Are there any changes to services required?

YesNo

Please list the people on this call:

Person being referred to Occupational Therapy

First Name *

Last Name *

Preferred Name

Date of Birth *

Phone Number

Email

Address *Include any specifics re parking or access

Referrer Details

We are self/primary contact referred

First Name

Last Name

Referrer's relationship to person

Other relationship

Referrer Phone

Referrer Email

The person being referred has given consent to this referral and consents to these details being kept on a cloud based client management system *

Referral Information

Describe why they would like help from Occupational Therapy (referral reason):

Person's diagnosis

Other information (e.g. best time to contact the person):

Please upload any reports or documentation associated with this referral

Browse

You can upload as many files as required

Who should we contact to make the appointment? *

ClientClient's main contactReferrer

Who should we send the Service Agreement to for signing? *

The Therapist for signing in person with the clientClient (please ensure the client has an email)Client's main contactReferrer (please ensure referrer has authority to sign on behalf of the client)

Who should we send the Consent Form to for signing? *

The Therapist for signing in person with the clientClient (please ensure the client has an email)Client's main contactReferrer (please ensure referrer has authority to sign on behalf of the client)

Main Contact/Emergency Contact

Please tick if the client is the main contact & does not have an Emergency Contact

Please confirm you have read the above about Emergency Contact and filled in section accordingly. *

First Name

Last Name

Relationship to person

Contact Phone number

Contact EmailPlease enter client's email address here if no alternative contact

Funding

Funding source *

NDIS Self ManagedNDIS Plan ManagedMy Aged Care / Home Care PackageOther

Other source

Priority *

High Medium Low

Please choose with consideration

Your client has had one or more falls during the past four weeks that has led to an injury or had an impact on their ability to complete their usual activities.
Your client has restricted their activities because they are worried about falling over or are dizzy.
Your client has had a recent decrease in their level of independence in usual activities and/or unable to perform most activities independently.

No recent change in independence in their usual activities or able to do most activities but with modification or assistance.

Minor impact on independence in usual activities or able to do most activities independently, or with minor modifications or difficulty.

Select Level of Care *

Approved Hours *

Number of Hours Available for Service *

NDIS Number *Please enter N/A if NDIS number is unknown

Start of Plan *Please enter Today's date for start/end plan dates if unknown

End of Plan *

Billing email address *Please enter N/A if billing email address is unknown

Plan Manager Company *

Plan managed billing email address *

Safety and Risk

The Participant has a behaviour support plan in place (we will request a copy of this at the time of engagement) *

YesNo

Please explain: *

Is anyone at your / the Participant’s property, known to be aggressive or violent? *

YesNo

Please explain: *

Is there a history of people using drugs or alcohol at the property? *

YesNo

Please explain: *

Are you aware of firearms on the clients property? *

YesNo

Please explain: *

Are you aware of any occupant having an infectious disease? (e.g. COVID, gastro, flu etc.) *

YesNo

Please explain: *

Are you aware of any risks related to pets or animals on the premises? *

YesNo

Please explain: *

Any other risk / safety factors you are aware of?

The risk information above is given with honesty and the answers are to the best of my ability *

Review by Admin

This Client is suitable for services *

YesYes - WaitlistFurther clarification requiredNo

Admin No *

Any further information or clarification required for Janelle

Review by Director

I accept this referral *

YesNo

If no, please provide reasoning: *

Ideal time frame for providing services *

Director - please note next steps for Admin

Next steps *

Admin setup case file in SploseAdmin send SA - please see below

Add Client to Waitlist

Service Agreement Requirements *Please specify how many hours or dollars for this SA

Send SA to Client

Send SA to Client's Representative

Send SA to Referrer

Director - please specify initial appointment details

Admin to attempt initial appointment booking *

YesNoWaitlist

Contact with the preferred party (Client/ClientRep/Referrer) *

CallCall and emailEmail

Admin to contact for arranging appointment:

Director to contact for arranging appointment:

The Client

The Client's Phone

The Client's Email

The Main Contact

The Main Contact Phone

The Main Contact Email

The Referrer

The Referrer's Phone

The Referrer's Email

Standing Order bookings (please select) *

Please book appointment within 3 weeks of referral for 1.5h appointment, any day, 2 x 30 mins travel (try to group together geographical areas)Stipulate exact appointment details below

Duration of Appointment *

1 hour1.5 hours2 hoursOther

Please specify other appointment duration *

1st Day suitable for booking appt *

Please specify the dates of 1st availability *

2nd Day suitable for booking appt *

Please specify the dates of 2nd availability *

Admin can offer 3rd appropriate day based on Calendar *

Yes - book awayNo - please contact Janelle

Travel inclusion required *

30 mins each wayOther

Please specify Travel required *

Final steps by Admin

Steps Taken

Setup file in Splose, add any documents attached to the Splose fileSplose ~ remember to choose 'Australia/Melbourne' as the timezoneSplose ~ add 'unsigned SA'/'pend cons form', 'funding' and 'company name/self managed' tag to the Splose profile under 'tags'Splose ~ add the 3 month report due reminder (3 months prior to end of plan - NDIS only)Add NDIS plan reminder date & expiry date to SploseTurn 'on' the case alert in Splose when creating a case (choose 3 months & 80%, Janelle)Add the 'NDIS End of Plan Report Due' Support Activity (3 months before the plan end date) - choose 'do not invoice' once createdAdd to Asana Setup client folder in iCloud and save referral there once completed (also save referral to Splose)

Waitlist - add client to Asana waitlist section & add to the Splose waitlist

Funding setup in Splose - either NDIS, Private or Home Care Package, Case added with start of referral date (no end date if HCP) with dollars approved pleaseClient setup in Xero with email field as the billing address, with Invoices 7 days

HCP Consent Form

NDIS Service Agreement

SA/Consent Form sent

Service Agreement/Consent form sent for signing (update Asana & Splose to 'pending SSA' or 'pend cons form' tag).

Review initial appointment information above

Email sent and commented on Asana Client task, to call the Client during suitable hours

Called Client/ClientRep/Referrer or Asana client task note made made to call the Client during suitable hours

Save and Complete Later