Positive Pathways OT - Occupational Therapy Service Referral

Referrer Details (Person Making the Referral)

First Name *

Last Name *

Email Address *

Agency

Role

Phone Number *

I have obtained consent from the participant to make this referral and provide Positive Pathways OT with the participant's personal and medical details. *

Client Details

First Name *

Last Name *

Date of Birth *

Phone Number *

Email Address *

Street Address *

City *

State *

Postcode *

Primary Disability/ Diagnosis *

Secondary Conditions or Concerns

Does the participant have any communication difficulties or requirements? *

YesNo

Does the participant have any restrictive practices in place? *

Yes No

Client Representative Details (If Applicable)

First Name

Last Name

Phone Number

Email

Company Name (If applicable)

Payment Method/Funding

What type of funding will be used to pay for services? *

NDIS Details

If utilising NDIS funding, please provide the following information:

Plan

Plan Managed Self Managed

Name of person/company for payment and/or invoices

Payment provider email

NDIS Number

Available funding for Occupational Therapy Services. (Funding for Occupational Therapy is listed under the Capacity Building category in your NDIS Plan)

Plan Start Date

Plan Review Date

Client Goals (As stated in the NDIS plan)

Other Payment Options

For all other payment options, please provide the following information:

Name of person/company for payment and invoicing

Payment provider email

Reference name/number for invoicing

Available funding for Occupational Therapy Services

Reason For Referral

Referral Reason *

Functional Capacity Assessment Supported Independent Living Assessment Assistive Technology Assessment Telehealth Functional Capacity AssessmentCarer Training and Education

Skill development and ongoing therapy services:
Skill development and ongoing therapy services are subject to availability and operate as a time limited service. Intervention is offered as a 12 week block of intervention (with a minimum of 12 hours of OT funding required) including an initial assessment, goal development and intervention with a targetted focus on areas including sensory intervention, independent living skill training (cleaning, meal preparation, laundry, self care), budgetting skills, social skills, travel training and more. Following intervention, a summary report will be provided. To enquire about our availability and intake processes for ongoing intervention, please contact admin@positivepathwaysot.com.

Additional Information regarding referral reason:

Risk Assessment

Is there any difficulties accessing the property?

YesNo Unknown

Is there ample parking near the appointment location?

Yes No Unknown

Will I be using the front door and will someone greet me upon arrival?

Yes No Unknown

Does the participant require an interpreter or have any communication needs?

Yes (please provide details in the 'other' section)No Unknown

Does the participant live alone?

Yes NoUnknown

Does anyone (including the participant) at the location have any behaviours of concern or risk?

Yes No Unknown

Are there any pets or animals at the premises?

Yes No Unknown

Is there a risk of illicit substance use at the premises?

Yes No Unknown

Is there a risk of firearms at the premises?

Yes No Unknown

File Upload - please upload any relevant files or information

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