Now Servicing: Gympie and Atherton Tablelands
About
NDIS
Home Care
Our Team
Locations
Atherton Tablelands
Gympie Region
Sunshine Coast
Moreton Bay Region
Brisbane Region
Services
Driving Assessments
Mental Health
Functional Assessments
Housing Assessments - SIL/SDA/ILO
Life Skills
Assistive Technology (AT)
Home Modifications
Children's Paediatric Occupational Therapy
Education
Careers
submit a referral
Contact Us
Home
Services
Our Team
Education
Careers
Submit a Referral
Contact Us
About
NDIS
Home Care
Our team
Locations
Atherton Tablelands
Gympie Region
Sunshine Coast
Moreton Bay Region
Brisbane Region
Services
All services
Driving Assessments
Mental Health
Functional Assessments
Housing Assessments - SIL/SDA/ILO
Life Skills
Assistive Technology (AT)
Home Modifications
Children's Paediatric Occupational Therapy
Education
Careers
submit a referral
contact us
Submit a referral
Submit a referral
What type of referral are you submitting?
NDIS
Home Care
DVA
Driving Assessments
NDIS Referral Form
Let's start with your details.
Enter your full name
Date of Birth (DD/MM/YYYY)
Address
Client Contact Phone Number
Client Email Address
Do you/participant identify as Indigenous or Torres Strait Islander descent?
Aboriginal
Torres Straight Islander
Aboriginal & Torres Straight Islander
None
Do not want to answer
Do you/participant have a cultural background or preference you want us to keep in mind?
Add your representatives details.
Support Coordinator Name
Support Coordinator Company
Support Coordinator Contact Number
Support Coordinator Email
Representative Contact Name.
NOK, POA, EPOA
Representative Contact Number
Consent to contact on my behalf?
Yes
No
Reason for occupational therapy assessment.
This will assist us to match you with the appropriate OT
Is this assessment urgent?
Yes
No
Add your NDIS Details.
NDIS Number
NDIS Funding
Self Managed
NDIS Managed
Plan Managed
Plan Manager name
Plan Manager email (for invoices)
NDIS Approved Disability
NDIS Goals
Referral Type
FCA – 15hr
SIL/ILO – 15hr
SDA – 25hr
Ongoing therapy – 15 hours
Major Modifications – 20 hours
Minor Modifications – 10 hours
Pressure Care Assessment – 10 hours
Add some final details.
Are there any behaviours of concern or a Positive Behaviour Support Plan? If yes – please upload your document.
Upload File
Max file size 10MB.
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Home Care Referral Form
Let's start with your details.
Enter your full name
Date of Birth (DD/MM/YYYY)
Address
Client Contact Phone Number
Do you/participant identify as Indigenous or Torres Strait Islander descent?
Aboriginal
Torres Straight Islander
Aboriginal & Torres Straight Islander
None
Do not want to answer
Do you/participant have a cultural background or preference you want us to keep in mind?
Next of Kin Details.
Full name
Contact Phone Number
Relationship (Next of Kin / EPOA / POA / Family Member)
Add some extra details.
Primary Diagnosis
Referral Type
Referrals for Functional and Safety Assessments
Home Care Package Extended Initial 3 hours $193.99 / Hour
Includes:
- Full Functional, Home Safety & Mobility Assessment
- Reporting
- Travel
Total Cost: $581.97 (incl. GST)
________
Referrals for Minor Mods or Equipment
Home Care Package Standard Initial 2 hours $193.99 / Hour
Includes:
- Initial Assessment
- Reporting
- Travel
Total Cost: $387.98 (incl. GST)
________
Package Provider Information .
Home Care Package Level
Case Manager Name
Case Manager Contact Details
Home Care Package Company
Thank you! Your submission has been received!
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DVA Referral Form
Let's start with your details.
Enter your full name
Date of Birth (DD/MM/YYYY)
Address
Client Contact Phone Number
Do you/participant identify as Indigenous or Torres Strait Islander descent?
Aboriginal
Torres Straight Islander
Aboriginal & Torres Straight Islander
None
Do not want to answer
Do you/participant have a cultural background or preference you want us to keep in mind?
Next of Kin Details.
Full name
Contact Phone Number
Relationship (Next of Kin / EPOA / POA / Family Member)
Add your DVA details.
DVA Number
DVA Card Status:
Gold
White
Please specify your treatable condition
GP Doctors Name
GP Clinic Name
GP Provider Number
If you have a D904 document, please attach below
Upload File
Max file size 10MB.
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Thank you! Your submission has been received!
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Driving Assessments Referral Form
Let's start with your details.
Enter your full name
Date of Birth (DD/MM/YYYY)
Address
Client Contact Phone Number
Client Email
Do you/participant identify as Indigenous or Torres Strait Islander descent?
Aboriginal
Torres Straight Islander
Aboriginal & Torres Straight Islander
None
Do not want to answer
Do you/participant have a cultural background or preference you want us to keep in mind?
Add NOK/EPOA/POA Details.
Full name
Contact Phone Number
Relationship (Next of Kin / EPOA / POA / Family Member)
Add Funding Informations.
Choose between NDIS, DVA, HCP
NDIS
DVA
HCP
Funidng Contact (Support coordinator, Case Manager or GP)
NDIS Number
NDIS Fundng type Self managed, NDIS Managed, Plan Managed
Plan Manager details
Attachment - Clearence from GP or Specialist
Upload File
Max file size 10MB.
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Attachment - QLD Transport Medical Certificate
Upload File
Max file size 10MB.
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Attachment Vision Assessment
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Max file size 10MB.
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Attachment Drivers license (back and front)
Upload File
Max file size 10MB.
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Attachment NDIS Plan or D904
Upload File
Max file size 10MB.
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Attcahments Past reports if any
Upload File
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Select required service.
Select one...
Senior Drivers Assessments
Learner Driver Assessments
Medical/Disability Assessments
Vehicle Modification for drivers
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