CLIENT DETAILS

First Name *

Last Name *

Address *

Suburb *

State *

Post Code *

Country *

Client Contact Number

Date of Birth *

Paediatric *

Gender *

Cultural Considerations? *

Primary Diagnosis

Medical Summary *

General Practitioner Full Name

GP Clinic Name

GP Clinic Contact Number

SERVICE DELIVERY

Preferred Service Delivery Method *In some cases Telehealth may be available with the option of Face 2 Face when the service becomes available. If this is option is considered please select "Soonest Available" to discuss further with one our Service Coordinators.

Appointment Details

Nearest Location *

Support Location - Cairns

Support Location - Townsville

Support Location - Ayr

Support Location - Mackay

Support Location - Sunshine Coast

Support Location - Brisbane

Support Location - Perth

Support Location - Telehealth

Support Location - Remote

Support Location - TBA

SERVICE REQUIREMENTS

OCCUPATIONAL THERAPY

Functional Needs Assessment (FNA)

Paediatric Initial Assessment

Assisted Technology / Equipment Request

Home Modification Assessment

Ongoing Therapy Sessions

PHYSIOTHERAPY

Physiotherapy Assessment

Ongoing Therapy Sessions

PSYCHOLOGY

Psychology Assessment

Ongoing Therapy Sessions

BEHAVIOUR SUPPORT

Behaviour Intervention Support

Behaviour Intervention Support (IDL Funding)

Behaviour Management Plan

SPEECH PATHOLOGY

Speech Assessment

Ongoing Therapy Sessions

ALLIED HEALTH

Allied Health Program

Ongoing Therapy Sessions

PRIMARY CONTACT / CLIENT REPRESENTATIVE

Primary Contact / Client Representative will be required to make decisions on behalf of the client eg. confirmation of services, client consent. Where additional parties are involved, responsibiltiy remains with the Primary Contact to distribute required communication.

C/O Primary Contact

Primary Contact Full Name *

Primary Contact Relationship to Client *

Primary Contact Email Address *

Primary Contact Phone Number *

I have checked the Primary Contact / Client Representative Email Address and can confirm it is correct. *

SUPPORT COORDINATION

Does the Client have a Support Coordinator or Child Safety Officer *

YesNo

Coordinator Company Name *

Coordinator Contact Name *

Coordinator Contact Number *

Coordinator Contact Email *

I have checked the Support Coordinator Email Address and can confirm it is correct. *

OFFICE OF PUBLIC GUARDIAN

Does this Client require consent from the Office of Public Guardian *

YesNo

PAYMENT OF SERVICES

Funding Source *

NDIS Plan Number *

NDIS Plan Start Date *

NDIS Plan End Date *

Referring Doctors Full Name

Referring Doctors Provider Number

Referral Date

Medicare Number

Medicare Reference Number

NDIS Plan Number - Private/Medicare

NDIS Plan Start Date - Private/Medicare

NDIS Plan End Date - Private/Medicare

Please upload your NDIS Plan

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Providing RAR Therapy with your NDIS Plan allows us our Therapist to work within your goals.

NDIA Allocation (Internal Use)

BILLING & ACCOUNTS

NDIS Plan Manager Company Name *

NDIS Plan Manager Contact Name *

NDIS Plan Manager Contact Number *

NDIS Plan Manager Email *

Billing Contact Name *

Billing Contact Number *

Billing Email Address *

I have checked the Billing Email Adress and can confirm it is correct. *

SUPPORTING DOCUMENTATION

Do you have any additional supporting documentation you would like to submit? *

YesNo

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CONFIRMATION

To avoid your services being placed on hold. Please only submit this referral form after checking and confirming that all responses are accurate and reletive to the Clients case/services. We often find email address details are incorrect causing important correspondance to bounce and or not be delivered. If this happens, it may cause a delay in services. For billing, please make sure the nominated billing address reflects the accounts department. Please mark checkbox if all details have been confirmed and you are happy to proceed. *

PRIVACY POLICY

I give consent to RAR Therapy to collect and use my personal and sensitive information as per the RAR Therapy Privacy Policy. *

HOW DID YOU HEAR ABOUT RAR THERAPY

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