Date of referral Client Details Preferred Pronoun He/Him She/Her They/Them Please provide full legal names Title Please select one ... Mr Mrs Ms Miss Master First Name Last Name Preferred Name Address Suburb Postcode Phone Contacts Email Address D.O.B Is this address a Nursing Home or an Aged Care Facility? Yes No Next of Kin Details (Person to contact in an emergency) First Name Last Name Contact Number Relationship to Client Package Details Funding Please select one ... NDIS TAC DVA WorkCover Private/Self Funded Other Claim or Package Number NDIS Plan Dates Number of hours available/approved Select Billing Method Please select one ... Plan Managed Agency Managed Self Managed Other Individualised Funding Plan Management Company Phone Email Support Coordinator Name Phone Email If 'Other' chosen for funding, please give details Medical History Please provide a summary of the client's Current AND Previous medical history: Please tick all of the applicable boxes below and provide details ABI Stroke Spinal cord injury Neurological condition Dementia Autism Spectrum Neurodevelopmental Disorder Please provide detailed medical history Has the person being referred ever had, OR do they currently have, an infectious disease? If yes, please provide FULL Details Yes No Mobility Status Cognitive Issues or concerns: (Memory, learning, perception, etc) Behavioural issues (Including any Personality disorders) Can the person communicate directly? Yes No Can the person understand written English? Yes No Is an interpreter required? Yes No Language Do you have any ethnic or religious beliefs you need us to be aware of? Yes No Service Request - please provide details of the service you require Full OT Assessment Home Modifications assessment ADL's Training (Activities of Daily Living) SDA or SIL Assessment Pressure care assessment / review Equipment review/assessment/prescription Postural seating assessment Please give details of the reason for referral Other services currently involved in therapy/treatment, e.g., Physiotherapist, Speech therapist, Neuropsychologist I give Peak Performance Occupational Therapy the authority to speak with any of my service providers during the period of support as agreed by all parties Yes No Referrer Details First Name Last Name Referrer Email Contact Number Relationship to Client Person to speak to for initial contact First Name Contact Number Which of the following do you require post-visit? Please select one ... Full Report 'Phone Discussion Email Other Terms Payment in full is required within 14 days of receipt of invoice The client will accept full liability for NDIS, Worksafe, TAC and DVA claims that are rejected Should payment remain outstanding beyond 21 days, the client is liable for all costs including legal costs (on a solicitor/own client basis) and costs incurred by Peak Performance Occupational Therapy. Accounts overdue by more than 60 days will be subject to interest of 2% per month from the date payment due until the date payment is made Cancellation of sessions must be made at least 48 hours prior to appointment. Peak Performance Occupational Therapy reserves the right to charge the full standard fee for failure to cancel your session within this time. NDIS invoices will be submitted to: client directly (if self-managed), or via Plan Managers Name Relationship to client Date By ticking this checkbox you acknowledge and accept the above terms Do you require an Advocate to be present during any or all of the therapy sessions or phone calls with the Occupational Therapist? Yes No If YES, please provide full details of Advocate
