Referral Form

CHILDS DETAILS

First Name *

Last Name *

Gender *

MaleFemalePrefer not to sayOther

Date of Birth *

Street Address

PARENT DETAILS

Parent Full Name *

Phone *

Email Address *

REFERRAL DETAILS

Services Required *

Occupational TherapyPsychologySpeech PathologyNutrition

Reason for Referral (choose all that apply) *

Assessment and Ongoing SessionsAssessment, Report and Ongoing SessionsAssessment and Report OnlyGroup Sessions (Holiday and After Hours Groups)OT Screener (Pre-school age screening)Other

Please provide more information around your presenting concerns:

Concern 1 *

Concern 2

Concern 3

Diagnosis (if any)

Other relevant information

Therapist Preference (please be advised this is subject to availability of therapist)

FemaleMaleNo PreferenceName

Please advise Name of preferred therapist

SUPPORT NEEDS

To ensure we meet your individual needs, could you please indicate if you:

Have no support needsRequire a language interpreterHave significant mobility issuesHave hearing loss requiring signing

If interpreter required please advise of language

FUNDING DETAILS

Please note that you will need to declare up front if the sessions are funded by NDIS, as additional requirements apply to providers such as the provision of Provider Support Plans (PSP) for NDIS reviews. If the sessions are not declared as NDIS upfront, then we will not be able to supply a PSP or other NDIS requirements for such services.

Funding *

NDISPrivate (Fee for Service or Private Health)Medicare - EPC/CDM (Enhanced Primary Care Plan)Medicare - MHCP (Mental Health Care Plan)Medicare - Allied Health Services For Indigenous Australians Who Have Had A Health CheckOther Third Party Funder (Government body (DCJ) or Out of Home Care, etc)

Please upload copy of Medicare plan from GP if available

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NDIS Type

NDIS CB Early InterventionNDIS CB Improved Daily LivingNDIS - UnsureAwaiting NDIS Approval

NDIS Number

NDIS Plan Start Date

NDIS Plan End Date

Please upload copy of NDIS plan if possible

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NDIS Funding Management

NDIA ManagedPlan Managed (third party payer manages invoices)Self ManagedUnsure

OTHER SERVICES

In relation to your previous service, What aspect were you happy with ?

Is there anything that made you unhappy with your previous therapy experiences?

AVAILABILITY

How did you find us?

Save and Complete Later

P (02) 4910 0777 | F (02) 4017 2419 | E admin@rainbowclinic.com.au | www.rainbowclinic.com.au

Suite 7, Level 2, 3 Hopetoun Street, Charlestown, NSW, 2290 | ABN: 29 612 885 677