Make an Occupational Therapy Referral CLIENT Full Name * First Name Last Name Date of Birth * Address Address 1 Address 2 City State/Province Zip/Postal Code Country NDIS Number Email * Client or Primary Contact Plan start and end dates Phone Number * Gender Living arrangements (family, alone, supported, etc.) Preferred language Primary Disability Co-morbid disability PRIMARY CONTACT (if any): Primary Contact Full Name * Relationship to client SUPPORT COORDINATOR/LAC: Support Coordinator Full Name Company Phone Number Email Address PLAN MANAGER (if any): Plan Manager Full Name Company Email Address Phone Number NDIA Managed Plan? * Yes No Self-managed Plan? * (invoices to send to clients email address otherwise stated Yes No Please email the following to ot@pacehm.com.au Additional relevant medical or therapy reports NDIS Plan Please list NDIS goals (if plan is emailed, please disregard) Funding Allocation Please provide number of funded hours for Occupational Therapy ($193.99/ hour) Assessment/service to be completed/provided: Functional Capacity Assessment Assessment Paediatric Functional Capacity Assessment) Complex Home Modifications Assistive Technology Supported Independent Living (SIL) Specialist Disability Accommodation (SDA) SIL/SDA General therapy (no assessment) Safety concerns? (Aggression, family members, drug use, etc.) Additional comments? Services Required Occupational Therapy Exercise Physiology Dietetics Thank you!
