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# Health First Group: We improve quality of life by providing personalised healthcare solutions.

## Sitemaps
[XML Sitemap](https://www.healthfirstgroup.com.au/sitemap_index.xml): Includes all crawlable and indexable pages.

## Posts
- [Discover Professional Physio Care at Health First Cairns](https://www.healthfirstgroup.com.au/blog/discover-professional-physio-care-at-health-first-cairns/): Experience top-quality physio care at Health First Cairns. Improve your wellbeing with expert treatment tailored to your needs. Schedule your appointment today!
- [Finding the Best Physiotherapy Services in Gladstone: A Guide](https://www.healthfirstgroup.com.au/blog/finding-the-best-physiotherapy-services-in-gladstone-a-guide/): Are you suffering from persistent pain and searching for quality physiotherapy services in Gladstone? If you're navigating the options for physical therapy, this concise guide will steer you toward the most suitable physio in Gladstone for your specific needs. By unraveling the offerings, scrutinising local clinics, and guiding you through the booking process, it aims to alleviate your discomfort and set you on the path to recovery. Understand the types of therapy, from hands-on massage to tailored exercise plans, and learn how to prepare effectively for your sessions to maximise your health in the long term. This content promises not just relief but also a clearer insight into managing and maintaining your well-being.
- [Finding the Right Physiotherapy Clinic in Albany: A Guide by Health First Group](https://www.healthfirstgroup.com.au/blog/finding-the-right-physiotherapy-clinic-in-albany-a-guide-by-health-first-group/): Are you struggling with persistent pain or seeking to enhance your physical health through physiotherapy in Albany? Navigating the options can be overwhelming, but the right clinic will not only address your discomfort but also foster your overall wellbeing. This post delves into essential considerations for selecting a physiotherapist, introduces you to the distinguished services at Health First Group and outlines their unique, patient-centered approach. With a focus on therapy techniques, including specialised Pilates sessions, the article aims to guide you towards making an informed decision. By the end, you'll have a clearer path to managing your health effectively with a trusted Albany-based physio.
- [Essential Tips for Finding a Physio in Bunbury](https://www.healthfirstgroup.com.au/blog/essential-tips-for-finding-a-physio-in-bunbury/): Are you struggling to find the right physiotherapist in Bunbury? This guide offers essential tips to help you choose a qualified physio who can address your specific health needs. We'll cover how to research local physiotherapists, verify their credentials, and assess their expertise in treating your particular injury or pain. You'll learn how to evaluate patient reviews, clinic facilities, and appointment availability, ensuring you find a therapist who can provide effective treatment and support your journey to better health through tailored exercises and therapy.
- [The Key to Choosing Quality Physiotherapy in Cairns](https://www.healthfirstgroup.com.au/blog/the-key-to-choosing-quality-physiotherapy-in-cairns/): Are you struggling to find the right physiotherapy care in Cairns? Choosing quality physical therapy is crucial for effective pain management and recovery. This guide will help you identify your specific needs, evaluate local clinics, and consider the qualifications of Cairns physiotherapists. By the end, you'll be equipped to make an informed decision about your health care, ensuring you receive the best physio Cairns has to offer for your therapy needs.
- [Navigating the Landscape of Pain Management: A Holistic Approach](https://www.healthfirstgroup.com.au/blog/navigating-the-landscape-of-pain-management-a-holistic-approach/): In this blog, we’ll explore the multifaceted world of pain management and delve into holistic approaches that encompass both traditional and alternative methods.
- [Harnessing Healing Power: The Transformative Nature of Therapeutic Exercise](https://www.healthfirstgroup.com.au/blog/harnessing-healing-power-the-transformative-nature-of-therapeutic-exercise/): In the pursuit of holistic well-being, therapeutic exercise emerges as a beacon of hope and healing. Beyond the conventional fitness routines, therapeutic exercise stands tall, offering a unique approach to rehabilitation, recovery, and overall wellness. 
- [The Healing Power of Exercise Therapy: A Holistic Approach to Wellness](https://www.healthfirstgroup.com.au/blog/the-healing-power-of-exercise-therapy-a-holistic-approach-to-wellness/): In a world where stress and sedentary lifestyles are becoming increasingly prevalent, the importance of maintaining physical and mental well-being cannot be overstated. One powerful and often underappreciated tool in the pursuit of holistic health is exercise therapy. 
- [Unlocking the Power of Physical Therapy: A Journey to Health and Wellness](https://www.healthfirstgroup.com.au/blog/unlocking-the-power-of-physical-therapy-a-journey-to-health-and-wellness/): Physical therapy is a dynamic and transformative field that plays a crucial role in restoring and enhancing the quality of life for individuals facing various health challenges. Whether recovering from an injury, managing a chronic condition, or seeking to optimise physical performance, physical therapy is a personalised and holistic approach that addresses the unique needs of each patient.
- [Empowering NDIS Individuals: How Health First Group’s Physiotherapy Services Make a Difference](https://www.healthfirstgroup.com.au/blog/empowering-ndis-individuals-how-health-first-groups-physiotherapy-services-make-a-difference/): Navigating life with a disability can present its unique set of challenges, but with the right support and services, the journey can become much smoother. If you or a loved one are registered under the National Disability Insurance Scheme (NDIS), you’ll be pleased to know that Health First Group offers specialised physiotherapy services by registered physiotherapists in Australia, available at physiotherapy clinics across the country.
- [Chronic Pain? Kalgoorlie Physio Has the Solutions You Need](https://www.healthfirstgroup.com.au/blog/chronic-pain-kalgoorlie-physio-has-the-solutions-you-need/): Chronic pain is a debilitating condition that can affect anyone, regardless of age or activity level. It can significantly impact your quality of life, making it difficult to work, enjoy hobbies, and maintain relationships. If you’re suffering from chronic pain, you know how frustrating and isolating it can be. 
- [Physio Bundaberg Benefits: Understanding the Benefits of Physiotherapy in Bundaberg](https://www.healthfirstgroup.com.au/blog/physio-bundaberg-benefits-understanding-the-benefits-of-physiotherapy-in-bundaberg/): Physiotherapy, a hidden gem in the healthcare realm, plays a pivotal role in helping you lead a pain-free and active life. In this article, we’ll dive into Physio Bundaberg benefits and how it can enhance your well-being.
- [The Role of Physiotherapy in Pain Management: A Physio Cairns Guide](https://www.healthfirstgroup.com.au/blog/the-role-of-physiotherapy-in-pain-management-a-physio-cairns-guide/): We all know that life can throw aches and pains our way, whether it’s from a day at the Great Barrier Reef or just the daily grind. But fear not, because there’s a friendly neighbourhood hero in the pain management game – physiotherapy. In this guide, we’ll delve deeper into how Physio Cairns can help you wave goodbye to those nagging discomforts.
- [The Role of Physiotherapy in Injury Rehabilitation: A Physio Hervey Bay Perspective](https://www.healthfirstgroup.com.au/blog/the-role-of-physiotherapy-in-injury-rehabilitation-a-physio-hervey-bay-perspective/): Picture this: You’re out on the pristine beaches of Hervey Bay, enjoying a beautiful day in the sun when, suddenly, you twist your ankle while playing beach volleyball. Ouch! It can happen to anyone. That’s where Physio Hervey Bay steps in, and we are here to help you bounce back to your active lifestyle.
- [Women’s and Men’s Health](https://www.healthfirstgroup.com.au/blog/womens-and-mens-health/): Men's and Women's Health
- [The Benefits of Physiotherapy in Pre and Post-Surgical Rehabilitation](https://www.healthfirstgroup.com.au/blog/the-benefits-of-physiotherapy-in-pre-and-post-surgical-rehabilitation/): Surgery can be a traumatic experience for many people, often requiring a significant amount of rehabilitation afterwards. Pre- and post-surgical rehabilitation is a crucial part of the recovery process, and physiotherapy plays a vital role in helping patients regain mobility and strength.
- [5 Reasons Why Physiotherapy Is Important in Our Daily Lives](https://www.healthfirstgroup.com.au/blog/why-physiotherapy-is-important/): Physiotherapy has been a recognized field in medicine for centuries, and in modern times, its popularity has only increased with the growing body of evidence advocating its effectiveness and the vital role of sports physiotherapists in both amateur and professional sports.
- [How Physiotherapy Can Help You Recover from Sports Injuries](https://www.healthfirstgroup.com.au/blog/physiotherapy-to-recover-from-sports-injuries/): Athletes of any level may experience frustrating setbacks due to sports injuries. The road to recovery can be a long and challenging one, regardless of the type of injury you’ve experienced, such as a sprained ankle or strain. Fortunately, physiotherapy can assist you in getting back up and playing.
- [NDIS At Health First Group](https://www.healthfirstgroup.com.au/blog/ndis-health-first-group/): Health First Group is a registered provider of physiotherapy services under the National Disability Insurance Scheme (NDIS). Originally registered as Total Physio Group, we completed the registration process in 2019 as a smaller company. As our company has grown in 2021, we successfully completed the audit process again and have been re-registered.
- [How to Fix Tennis Elbow Pain (In 21 Days or Less)](https://www.healthfirstgroup.com.au/blog/fix-tennis-elbow-pain/): Tennis Elbows, similar to a golfer's elbow, the tendons of the forearm can suffer overloading in activities like tennis, which led to the common name of “tennis elbow.” Often caused by repetitive motions of the upper arm and wrist, tennis elbow is a painful condition that occurs when the tendons in the elbow are chronically overloaded. 
- [Health First Group Employee Value Proposition](https://www.healthfirstgroup.com.au/blog/health-first-group-employee-value-proposition/): An Employee Value Proposition (EVP) is a unique set of benefits that an employee receives in return for the skills, capabilities, and experience they bring to a company. The way I look at it is that it's a summary of why people would join us, and stay with us. What makes us different? It's a hard market out there for Allied Health employers at the moment and it's not unheard of for even new graduates to have 10+ offers of employment when they graduate. The tables have somewhat turned from when I was a new grad. I remember being told at my first ever interview at a large hospital in London that over 250 people had applied for only 6 positions.
- [Health First Group – New Grad Program 2023](https://www.healthfirstgroup.com.au/blog/health-first-group-new-grad-program-2023/): As 2022 continues, we are looking for the next generation of physiotherapists and allied health professionals. Our New Grad program is designed to develop you into a private practice clinician. Providing all of the necessary resources to help build on the foundations that your education has provided you, as well as help to further develop your manual therapy skills. Our aim is to give you the tools and experience to increase your confidence as a physiotherapist and provide you with a supportive learning experience in a dynamic business environment.
- [Can You Eat Chocolate and Be Healthy?](https://www.healthfirstgroup.com.au/blog/can-you-eat-chocolate-and-be-healthy/): Did you know that today is National Chocolate Day!? Whether you have a sweet tooth or not, chocolate is a treat that many people enjoy. Some might indulge weekly, monthly, or even less frequently. However, chocolate is classified as a discretionary food. 
- [Getting to the Core](https://www.healthfirstgroup.com.au/blog/getting-to-the-core/): Clinical Pilates is an excellent form of low-impact exercise that focuses attention on the ‘core muscles’ of the body.  This helps to give balanced muscular strength development throughout the back and limbs, helping to stabilise your spine.  Excellent news for the huge proportion of people that suffer from long-term back pain.
- [The 80:20 approach to a healthy lifestyle](https://www.healthfirstgroup.com.au/blog/the-8020-lifestyle-approach/): Our dietitian, Stephanie Blackwell, suggests that the 80:20 rule is a healthy, less-restrictive lifestyle option that anyone can follow. This approach promotes balance and moderation rather than strict dieting. To succeed with other strict diets, you must follow them 100% of the time, whereas the 80:20 rule allows you to indulge in your favourite foods 20% of the time while ensuring you follow healthy eating advice for the remaining 80%.
- [Why you should work regionally in allied health](https://www.healthfirstgroup.com.au/blog/working-regionally/): Not only will you receive great training and development through “patient mileage”, but companies are forced to provide more for their staff to attract them regionally. Secondly, there are often government grants for working regionally - some have stipulations such as 12-month contract length, but often you can have courses fully paid for, including travel and accommodation. Grants can depend on the state, and your “regional” rating, but in some instances, they can be upwards of $10,000 per year. A great incentive, especially for newer graduates who want to focus on learning and development in their first few years.
- [How to stop knee-pain at night](https://www.healthfirstgroup.com.au/blog/how-to-stop-knee-pain-at-night/): You go the whole day with hardly any knee pain, and then boom! The moment you lay down for some shut-eye, it starts throbbing!
- [5 tips for doing your home exercise program](https://www.healthfirstgroup.com.au/blog/5-tips-for-doing-your-home-exercise-program/): As Physiotherapists, we give our patients ‘homework’ in the form of a home exercise program to help keep their rehab up to scratch between appointments. Whilst it’s not the most popular form of treatment we provide, believe us when we say it is certainly one of the most important (and successful).
- [5 reasons to treat your back pain with Spinal Decompression Therapy](https://www.healthfirstgroup.com.au/blog/treat-your-back-pain-with-spinal-decompression-therapy/): In this post, we’ll discuss the alternative, Spinal Decompression Therapy and highlight 5 reasons that support its use, backed by the growing body of medical evidence.
- [What is Bursitis and why is it so painful?](https://www.healthfirstgroup.com.au/blog/what-is-bursitis-and-why-is-it-so-painful/): Bursitis is characterised by swelling of the bursae. Bursae are fluid-filled sacs which act as a cushion for the tendons, ligaments, and muscles of the body, allowing smooth movements of these structures. Sometimes the bursae become swollen, leading to the area around them becoming extremely tender and painful. This condition is known as bursitis.
- [Are you tired of constant foot pain?](https://www.healthfirstgroup.com.au/blog/are-you-tired-of-foot-pain/): Plantar fasciitis is a common foot pain injury associated with activities that require jumping, running, or repetitive loading. Most athletes will experience pain on the base of the heel or arch when landing or pushing off, especially with the first steps in the morning. There may be stiffness associated with it before it starts to ease. 
- [What is cross training and why is it important?](https://www.healthfirstgroup.com.au/blog/cross-training-and-its-importance/): Cross training is defined as "the action or practice of engaging in two or more sports or types of exercise in order to improve fitness or performance in one’s main sport." This versatile training method involves diversifying your exercise routine by incorporating various forms of physical activity. 
- [Tennis Elbow](https://www.healthfirstgroup.com.au/blog/tennis-elbow/): Tennis elbow, also known as lateral epicondylitis, is one of the most common injuries of the arm, and a condition that we regularly see in the clinic. It is a degenerative, or failed healing response to the wrist extensor tendon, and most commonly affects the origin of the extensor carpi radialis brevis muscle. 
- [Chronic Ankle Instability](https://www.healthfirstgroup.com.au/blog/chronic-ankle-instability/): Does your ankle keep rolling? Ankle sprains account for up to one third of all sports injuries. About a further 30% of patients may develop chronic ankle instability (CAI), which greatly limits their professional or recreational activities. 
- [What is Shockwave Therapy](https://www.healthfirstgroup.com.au/blog/shockwave-therapy/): Shockwave therapy has emerged as a viable treatment option for patients with chronic tendon problems. The procedure uses either pressurised air or electromagnetic pulses to deliver shock waves to the body, helping to treat a variety of chronic disorders, including:
- [Cervicogenic headaches](https://www.healthfirstgroup.com.au/blog/cervicogenic-headaches/): We see a lot of people who suffer from headaches. Many headaches originate in the neck, and these are technically called cervicogenic headaches. They result from dysfunction within the top three vertebral segments of the spine. Dysfunction in the neck causes head pain in two distinct ways.
- [Dry needling](https://www.healthfirstgroup.com.au/blog/dry-needling/): Dry Needling (DN) is a method of treatment for taut bands of soft tissue, such as muscle or connective tissue, that may contribute to your pain and limit your movement. It can assist in reducing pain, muscular spasm, and sensitivity of tender areas, known as trigger points. 

## Pages
- [OT Referral Form Mackay](https://www.healthfirstgroup.com.au/ot-referral-form-mackay/): OT Referral Form Mackay PhoneThis field is for validation purposes and should be left unchanged.REFERRER DETAILSDate(Required) MM slash DD slash YYYY Name(Required)Email(Required) OrganizationContact Number(Required)CLIENT DETAILSClient Name(Required)Contact Number(Required)Client Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country D.O.B.Email(Required) Please tick any of the following that apply to the participant’s current situation: PBSP MHA ILO SDA SIL RatioDoes the participant require additional support to facilitate communication? e.g. interpreter, signer, etc.Preferred Method of Contact (SC/Direct/Alternative Contact)Who will sign the service agreement?(Required) Participant OPG Plan Nominee/EPOA Emergency Contact Details (Name, Number, Relationship)(Required)NDIS DETAILSNDIS No.(Required)Plan Dates(Required)Support Coordinator(Required)Email(Required) Plan Management Type(Required) Plan Managed Agency Managed Self-Managed Plan Management DetailsEmail(Required) Primary DisabilitySecondary DisabilitiesDoes the participant have any support / services in place?GPOrganisationPhoneEmail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Payment of AccountWho is responsible for paying the account? NDIS Portal and I authorise RTS to create a Service Booking for the hours nominated in a signed service agreement. Registered Plan Manager (please complete details below) Self (please complete details below) Name of Plan Management Organisation (if applicable):Which NDIS funding source should we be utilising? Core Funding Improved Daily Living Name of the person responsible for the accountPhoneEmail for invoices to be forwarded: REFERRAL FORMSERVICES REQUESTED Functional Capacity Assessment & NDIS Review Report Environment Assessment Occupational Support Profile & Report (not intended for NDIS plan reviews) Home and Living: S-I-L Assessment & S-I-L Report Home and Living: ILO AT Assessment & Letter of Support ONGOING THERAPY Routine Establishment Sensory Assessment & Sensory Modulation Plan Cognitive Assessment & Strategy Training Activities of Daily Living Training, Community & Life Skills Training DURATION OF SERVICE Assessment Report & Discharge Assessment Report & Ongoing Therapy Ongoing Therapy ADDITIONAL INFORMATIONIn your opinion, is the client best suited for one extended
2-hour assessment appointment or 2 x 1 hour appointment?
(Please consider the clients ability to maintain focus and
engagement) 1 x 2 hour 2 x 1 hour N/A – Ongoing Therapy MEDICAL HISTORYPlease provide a summary of the client’s Current AND Previous medical history: Please tick all the applicable boxes below and provide details: ABI Stroke Spinal cord injury Neurological condition Dementia Bipolar / Schizophrenia Disorder Depression / Anxiety Disorder Autism Spectrum Neurodevelopmental Disorder Intellectual Disability Other Mental Health Diagnosis Please provide detailed medical history belowHas the person being referred ever had, OR do they currently have, an infectious disease? If YES, please provide full details YES NO Details(Required)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 Interpreter required: YES NO Language(Required)Do you have any ethnic or religious beliefs you need us to be aware of? YES NO If yes, provide details(Required)Service Request - please provide details of the service you requireService Request - please provide details of the service you require Full OT Assessment Carer assessment and/or carer training Computer-Based Therapy – Clinic 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 below:(Required)Other services currently involved in therapy/treatment:i.e., Physiotherapist, Speech Therapist, NeuropsychologistI give Health First Group the authority to speak with any of my service providers during the period of support as agreed by all parties. YES NO REFERRAL FORMADDITIONAL INFORMATIONHas the participant ever received support from an Occupational Therapist? Any additional information or complexities to be aware of to ensure the participant is well supported?Any additional information or complexities to be aware of to ensure the participant is well
supported? SAFETY ISSUESFor the safety of staff, please outline if there are any safety considerations to be aware of
when visiting the client in their home:Is anyone at the property known to be aggressive or violent? If so, will there be a support worker / support coordinator / carer present for the appointment, or would you recommend two therapists attend?Are you aware of there being firearms, weapons, sharps or other drug paraphernalia at the property?Are you aware of any occupant having infectious disease (e.g., flu symptoms, gastro, MRSA)?Are you aware of any pets/animals in the premises? If so, please describe. Save & Continue Δ
- [OT Referral Form Albany](https://www.healthfirstgroup.com.au/ot-referral-form-albany/): OT Referral Form Albany InstagramThis field is for validation purposes and should be left unchanged.REFERRER DETAILSDate(Required) MM slash DD slash YYYY Name(Required)Email(Required) OrganizationContact Number(Required)CLIENT DETAILSClient Name(Required)Contact Number(Required)Client Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country D.O.B.Email(Required) Please tick any of the following that apply to the participant’s current situation: PBSP MHA ILO SDA SIL RatioDoes the participant require additional support to facilitate communication? e.g. interpreter, signer, etc.Preferred Method of Contact (SC/Direct/Alternative Contact)Who will sign the service agreement?(Required) Participant OPG Plan Nominee/EPOA Emergency Contact Details (Name, Number, Relationship)(Required)NDIS DETAILSNDIS No.(Required)Plan Dates(Required)Support Coordinator(Required)Email(Required) Plan Management Type(Required) Plan Managed Agency Managed Self-Managed Plan Management DetailsEmail(Required) Primary DisabilitySecondary DisabilitiesDoes the participant have any support / services in place?GPOrganisationPhoneEmail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Payment of AccountWho is responsible for paying the account? NDIS Portal and I authorise RTS to create a Service Booking for the hours nominated in a signed service agreement. Registered Plan Manager (please complete details below) Self (please complete details below) Name of Plan Management Organisation (if applicable):Which NDIS funding source should we be utilising? Core Funding Improved Daily Living Name of the person responsible for the accountPhoneEmail for invoices to be forwarded: REFERRAL FORMSERVICES REQUESTED Functional Capacity Assessment & NDIS Review Report Environment Assessment Occupational Support Profile & Report (not intended for NDIS plan reviews) Home and Living: S-I-L Assessment & S-I-L Report Home and Living: ILO AT Assessment & Letter of Support ONGOING THERAPY Routine Establishment Sensory Assessment & Sensory Modulation Plan Cognitive Assessment & Strategy Training Activities of Daily Living Training, Community & Life Skills Training DURATION OF SERVICE Assessment Report & Discharge Assessment Report & Ongoing Therapy Ongoing Therapy ADDITIONAL INFORMATIONIn your opinion, is the client best suited for one extended
2-hour assessment appointment or 2 x 1 hour appointment?
(Please consider the clients ability to maintain focus and
engagement) 1 x 2 hour 2 x 1 hour N/A – Ongoing Therapy MEDICAL HISTORYPlease provide a summary of the client’s Current AND Previous medical history: Please tick all the applicable boxes below and provide details: ABI Stroke Spinal cord injury Neurological condition Dementia Bipolar / Schizophrenia Disorder Depression / Anxiety Disorder Autism Spectrum Neurodevelopmental Disorder Intellectual Disability Other Mental Health Diagnosis Please provide detailed medical history belowHas the person being referred ever had, OR do they currently have, an infectious disease? If YES, please provide full details YES NO Details(Required)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 Interpreter required: YES NO Language(Required)Do you have any ethnic or religious beliefs you need us to be aware of? YES NO If yes, provide details(Required)Service Request - please provide details of the service you requireService Request - please provide details of the service you require Full OT Assessment Carer assessment and/or carer training Computer-Based Therapy – Clinic 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 below:(Required)Other services currently involved in therapy/treatment:i.e., Physiotherapist, Speech Therapist, NeuropsychologistI give Health First Group the authority to speak with any of my service providers during the period of support as agreed by all parties. YES NO REFERRAL FORMADDITIONAL INFORMATIONHas the participant ever received support from an Occupational Therapist? Any additional information or complexities to be aware of to ensure the participant is well supported?Any additional information or complexities to be aware of to ensure the participant is well
supported? SAFETY ISSUESFor the safety of staff, please outline if there are any safety considerations to be aware of
when visiting the client in their home:Is anyone at the property known to be aggressive or violent? If so, will there be a support worker / support coordinator / carer present for the appointment, or would you recommend two therapists attend?Are you aware of there being firearms, weapons, sharps or other drug paraphernalia at the property?Are you aware of any occupant having infectious disease (e.g., flu symptoms, gastro, MRSA)?Are you aware of any pets/animals in the premises? If so, please describe. Save & Continue Δ
- [OT Referral Form Gladstone](https://www.healthfirstgroup.com.au/ot-referral-form-gladstone/): OT Referral Form Gladstone EmailThis field is for validation purposes and should be left unchanged.REFERRER DETAILSDate(Required) MM slash DD slash YYYY Name(Required)Email(Required) OrganizationContact Number(Required)CLIENT DETAILSClient Name(Required)Contact Number(Required)Client Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country D.O.B.Email(Required) Please tick any of the following that apply to the participant’s current situation: PBSP MHA ILO SDA SIL RatioDoes the participant require additional support to facilitate communication? e.g. interpreter, signer, etc.Preferred Method of Contact (SC/Direct/Alternative Contact)Who will sign the service agreement?(Required) Participant OPG Plan Nominee/EPOA Emergency Contact Details (Name, Number, Relationship)(Required)NDIS DETAILSNDIS No.(Required)Plan Dates(Required)Support Coordinator(Required)Email(Required) Plan Management Type(Required) Plan Managed Agency Managed Self-Managed Plan Management DetailsEmail(Required) Primary DisabilitySecondary DisabilitiesDoes the participant have any support / services in place?GPOrganisationPhoneEmail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Payment of AccountWho is responsible for paying the account? NDIS Portal and I authorise RTS to create a Service Booking for the hours nominated in a signed service agreement. Registered Plan Manager (please complete details below) Self (please complete details below) Name of Plan Management Organisation (if applicable):Which NDIS funding source should we be utilising? Core Funding Improved Daily Living Name of the person responsible for the accountPhoneEmail for invoices to be forwarded: REFERRAL FORMSERVICES REQUESTED Functional Capacity Assessment & NDIS Review Report Environment Assessment Occupational Support Profile & Report (not intended for NDIS plan reviews) Home and Living: S-I-L Assessment & S-I-L Report Home and Living: ILO AT Assessment & Letter of Support ONGOING THERAPY Routine Establishment Sensory Assessment & Sensory Modulation Plan Cognitive Assessment & Strategy Training Activities of Daily Living Training, Community & Life Skills Training DURATION OF SERVICE Assessment Report & Discharge Assessment Report & Ongoing Therapy Ongoing Therapy ADDITIONAL INFORMATIONIn your opinion, is the client best suited for one extended
2-hour assessment appointment or 2 x 1 hour appointment?
(Please consider the clients ability to maintain focus and
engagement) 1 x 2 hour 2 x 1 hour N/A – Ongoing Therapy MEDICAL HISTORYPlease provide a summary of the client’s Current AND Previous medical history: Please tick all the applicable boxes below and provide details: ABI Stroke Spinal cord injury Neurological condition Dementia Bipolar / Schizophrenia Disorder Depression / Anxiety Disorder Autism Spectrum Neurodevelopmental Disorder Intellectual Disability Other Mental Health Diagnosis Please provide detailed medical history belowHas the person being referred ever had, OR do they currently have, an infectious disease? If YES, please provide full details YES NO Details(Required)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 Interpreter required: YES NO Language(Required)Do you have any ethnic or religious beliefs you need us to be aware of? YES NO If yes, provide details(Required)Service Request - please provide details of the service you requireService Request - please provide details of the service you require Full OT Assessment Carer assessment and/or carer training Computer-Based Therapy – Clinic 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 below:(Required)Other services currently involved in therapy/treatment:i.e., Physiotherapist, Speech Therapist, NeuropsychologistI give Health First Group the authority to speak with any of my service providers during the period of support as agreed by all parties. YES NO REFERRAL FORMADDITIONAL INFORMATIONHas the participant ever received support from an Occupational Therapist? Any additional information or complexities to be aware of to ensure the participant is well supported?Any additional information or complexities to be aware of to ensure the participant is well
supported? SAFETY ISSUESFor the safety of staff, please outline if there are any safety considerations to be aware of
when visiting the client in their home:Is anyone at the property known to be aggressive or violent? If so, will there be a support worker / support coordinator / carer present for the appointment, or would you recommend two therapists attend?Are you aware of there being firearms, weapons, sharps or other drug paraphernalia at the property?Are you aware of any occupant having infectious disease (e.g., flu symptoms, gastro, MRSA)?Are you aware of any pets/animals in the premises? If so, please describe. Save & Continue Δ
- [OT Referral Form Rockhampton](https://www.healthfirstgroup.com.au/ot-referral-form-rockhampton/): OT Referral Form Rockhampton CompanyThis field is for validation purposes and should be left unchanged.REFERRER DETAILSDate(Required) MM slash DD slash YYYY Name(Required)Email(Required) OrganizationContact Number(Required)CLIENT DETAILSClient Name(Required)Contact Number(Required)Client Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country D.O.B.Email(Required) Please tick any of the following that apply to the participant’s current situation: PBSP MHA ILO SDA SIL RatioDoes the participant require additional support to facilitate communication? e.g. interpreter, signer, etc.Preferred Method of Contact (SC/Direct/Alternative Contact)Who will sign the service agreement?(Required) Participant OPG Plan Nominee/EPOA Emergency Contact Details (Name, Number, Relationship)(Required)NDIS DETAILSNDIS No.(Required)Plan Dates(Required)Support Coordinator(Required)Email(Required) Plan Management Type(Required) Plan Managed Agency Managed Self-Managed Plan Management DetailsEmail(Required) Primary DisabilitySecondary DisabilitiesDoes the participant have any support / services in place?GPOrganisationPhoneEmail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Payment of AccountWho is responsible for paying the account? NDIS Portal and I authorise RTS to create a Service Booking for the hours nominated in a signed service agreement. Registered Plan Manager (please complete details below) Self (please complete details below) Name of Plan Management Organisation (if applicable):Which NDIS funding source should we be utilising? Core Funding Improved Daily Living Name of the person responsible for the accountPhoneEmail for invoices to be forwarded: REFERRAL FORMSERVICES REQUESTED Functional Capacity Assessment & NDIS Review Report Environment Assessment Occupational Support Profile & Report (not intended for NDIS plan reviews) Home and Living: S-I-L Assessment & S-I-L Report Home and Living: ILO AT Assessment & Letter of Support ONGOING THERAPY Routine Establishment Sensory Assessment & Sensory Modulation Plan Cognitive Assessment & Strategy Training Activities of Daily Living Training, Community & Life Skills Training DURATION OF SERVICE Assessment Report & Discharge Assessment Report & Ongoing Therapy Ongoing Therapy ADDITIONAL INFORMATIONIn your opinion, is the client best suited for one extended
2-hour assessment appointment or 2 x 1 hour appointment?
(Please consider the clients ability to maintain focus and
engagement) 1 x 2 hour 2 x 1 hour N/A – Ongoing Therapy MEDICAL HISTORYPlease provide a summary of the client’s Current AND Previous medical history: Please tick all the applicable boxes below and provide details: ABI Stroke Spinal cord injury Neurological condition Dementia Bipolar / Schizophrenia Disorder Depression / Anxiety Disorder Autism Spectrum Neurodevelopmental Disorder Intellectual Disability Other Mental Health Diagnosis Please provide detailed medical history belowHas the person being referred ever had, OR do they currently have, an infectious disease? If YES, please provide full details YES NO Details(Required)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 Interpreter required: YES NO Language(Required)Do you have any ethnic or religious beliefs you need us to be aware of? YES NO If yes, provide details(Required)Service Request - please provide details of the service you requireService Request - please provide details of the service you require Full OT Assessment Carer assessment and/or carer training Computer-Based Therapy – Clinic 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 below:(Required)Other services currently involved in therapy/treatment:i.e., Physiotherapist, Speech Therapist, NeuropsychologistI give Health First Group the authority to speak with any of my service providers during the period of support as agreed by all parties. YES NO REFERRAL FORMADDITIONAL INFORMATIONHas the participant ever received support from an Occupational Therapist? Any additional information or complexities to be aware of to ensure the participant is well supported?Any additional information or complexities to be aware of to ensure the participant is well
supported? SAFETY ISSUESFor the safety of staff, please outline if there are any safety considerations to be aware of
when visiting the client in their home:Is anyone at the property known to be aggressive or violent? If so, will there be a support worker / support coordinator / carer present for the appointment, or would you recommend two therapists attend?Are you aware of there being firearms, weapons, sharps or other drug paraphernalia at the property?Are you aware of any occupant having infectious disease (e.g., flu symptoms, gastro, MRSA)?Are you aware of any pets/animals in the premises? If so, please describe. Save & Continue Δ
- [OT Referral Form Bundaberg](https://www.healthfirstgroup.com.au/ot-referral-form-bundaberg/): OT Referral Form Bundaberg CompanyThis field is for validation purposes and should be left unchanged.REFERRER DETAILSDate(Required) MM slash DD slash YYYY Name(Required)Email(Required) OrganizationContact Number(Required)CLIENT DETAILSClient Name(Required)Contact Number(Required)Client Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country D.O.B.Email(Required) Please tick any of the following that apply to the participant’s current situation: PBSP MHA ILO SDA SIL RatioDoes the participant require additional support to facilitate communication? e.g. interpreter, signer, etc.Preferred Method of Contact (SC/Direct/Alternative Contact)Who will sign the service agreement?(Required) Participant OPG Plan Nominee/EPOA Emergency Contact Details (Name, Number, Relationship)(Required)NDIS DETAILSNDIS No.(Required)Plan Dates(Required)Support Coordinator(Required)Email(Required) Plan Management Type(Required) Plan Managed Agency Managed Self-Managed Plan Management DetailsEmail(Required) Primary DisabilitySecondary DisabilitiesDoes the participant have any support / services in place?GPOrganisationPhoneEmail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Payment of AccountWho is responsible for paying the account? NDIS Portal and I authorise RTS to create a Service Booking for the hours nominated in a signed service agreement. Registered Plan Manager (please complete details below) Self (please complete details below) Name of Plan Management Organisation (if applicable):Which NDIS funding source should we be utilising? Core Funding Improved Daily Living Name of the person responsible for the accountPhoneEmail for invoices to be forwarded: REFERRAL FORMSERVICES REQUESTED Functional Capacity Assessment & NDIS Review Report Environment Assessment Occupational Support Profile & Report (not intended for NDIS plan reviews) Home and Living: S-I-L Assessment & S-I-L Report Home and Living: ILO AT Assessment & Letter of Support ONGOING THERAPY Routine Establishment Sensory Assessment & Sensory Modulation Plan Cognitive Assessment & Strategy Training Activities of Daily Living Training, Community & Life Skills Training DURATION OF SERVICE Assessment Report & Discharge Assessment Report & Ongoing Therapy Ongoing Therapy ADDITIONAL INFORMATIONIn your opinion, is the client best suited for one extended
2-hour assessment appointment or 2 x 1 hour appointment?
(Please consider the clients ability to maintain focus and
engagement) 1 x 2 hour 2 x 1 hour N/A – Ongoing Therapy MEDICAL HISTORYPlease provide a summary of the client’s Current AND Previous medical history: Please tick all the applicable boxes below and provide details: ABI Stroke Spinal cord injury Neurological condition Dementia Bipolar / Schizophrenia Disorder Depression / Anxiety Disorder Autism Spectrum Neurodevelopmental Disorder Intellectual Disability Other Mental Health Diagnosis Please provide detailed medical history belowHas the person being referred ever had, OR do they currently have, an infectious disease? If YES, please provide full details YES NO Details(Required)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 Interpreter required: YES NO Language(Required)Do you have any ethnic or religious beliefs you need us to be aware of? YES NO If yes, provide details(Required)Service Request - please provide details of the service you requireService Request - please provide details of the service you require Full OT Assessment Carer assessment and/or carer training Computer-Based Therapy – Clinic 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 below:(Required)Other services currently involved in therapy/treatment:i.e., Physiotherapist, Speech Therapist, NeuropsychologistI give Health First Group the authority to speak with any of my service providers during the period of support as agreed by all parties. YES NO REFERRAL FORMADDITIONAL INFORMATIONHas the participant ever received support from an Occupational Therapist? Any additional information or complexities to be aware of to ensure the participant is well supported?Any additional information or complexities to be aware of to ensure the participant is well
supported? SAFETY ISSUESFor the safety of staff, please outline if there are any safety considerations to be aware of
when visiting the client in their home:Is anyone at the property known to be aggressive or violent? If so, will there be a support worker / support coordinator / carer present for the appointment, or would you recommend two therapists attend?Are you aware of there being firearms, weapons, sharps or other drug paraphernalia at the property?Are you aware of any occupant having infectious disease (e.g., flu symptoms, gastro, MRSA)?Are you aware of any pets/animals in the premises? If so, please describe. Save & Continue Δ
- [OT Referral Form Shepparton](https://www.healthfirstgroup.com.au/ot-referral-form-shepparton/): OT Referral Form Shepparton CompanyThis field is for validation purposes and should be left unchanged.REFERRER DETAILSDate(Required) MM slash DD slash YYYY Name(Required)Email(Required) OrganizationContact Number(Required)CLIENT DETAILSClient Name(Required)Contact Number(Required)Client Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country D.O.B.Email(Required) Please tick any of the following that apply to the participant’s current situation: PBSP MHA ILO SDA SIL RatioDoes the participant require additional support to facilitate communication? e.g. interpreter, signer, etc.Preferred Method of Contact (SC/Direct/Alternative Contact)Who will sign the service agreement?(Required) Participant OPG Plan Nominee/EPOA Emergency Contact Details (Name, Number, Relationship)(Required)NDIS DETAILSNDIS No.(Required)Plan Dates(Required)Support Coordinator(Required)Email(Required) Plan Management Type(Required) Plan Managed Agency Managed Self-Managed Plan Management DetailsEmail(Required) Primary DisabilitySecondary DisabilitiesDoes the participant have any support / services in place?GPOrganisationPhoneEmail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Payment of AccountWho is responsible for paying the account? NDIS Portal and I authorise RTS to create a Service Booking for the hours nominated in a signed service agreement. Registered Plan Manager (please complete details below) Self (please complete details below) Name of Plan Management Organisation (if applicable):Which NDIS funding source should we be utilising? Core Funding Improved Daily Living Name of the person responsible for the accountPhoneEmail for invoices to be forwarded: REFERRAL FORMSERVICES REQUESTED Functional Capacity Assessment & NDIS Review Report Environment Assessment Occupational Support Profile & Report (not intended for NDIS plan reviews) Home and Living: S-I-L Assessment & S-I-L Report Home and Living: ILO AT Assessment & Letter of Support ONGOING THERAPY Routine Establishment Sensory Assessment & Sensory Modulation Plan Cognitive Assessment & Strategy Training Activities of Daily Living Training, Community & Life Skills Training DURATION OF SERVICE Assessment Report & Discharge Assessment Report & Ongoing Therapy Ongoing Therapy ADDITIONAL INFORMATIONIn your opinion, is the client best suited for one extended
2-hour assessment appointment or 2 x 1 hour appointment?
(Please consider the clients ability to maintain focus and
engagement) 1 x 2 hour 2 x 1 hour N/A – Ongoing Therapy MEDICAL HISTORYPlease provide a summary of the client’s Current AND Previous medical history: Please tick all the applicable boxes below and provide details: ABI Stroke Spinal cord injury Neurological condition Dementia Bipolar / Schizophrenia Disorder Depression / Anxiety Disorder Autism Spectrum Neurodevelopmental Disorder Intellectual Disability Other Mental Health Diagnosis Please provide detailed medical history belowHas the person being referred ever had, OR do they currently have, an infectious disease? If YES, please provide full details YES NO Details(Required)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 Interpreter required: YES NO Language(Required)Do you have any ethnic or religious beliefs you need us to be aware of? YES NO If yes, provide details(Required)Service Request - please provide details of the service you requireService Request - please provide details of the service you require Full OT Assessment Carer assessment and/or carer training Computer-Based Therapy – Clinic 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 below:(Required)Other services currently involved in therapy/treatment:i.e., Physiotherapist, Speech Therapist, NeuropsychologistI give Health First Group the authority to speak with any of my service providers during the period of support as agreed by all parties. YES NO REFERRAL FORMADDITIONAL INFORMATIONHas the participant ever received support from an Occupational Therapist? Any additional information or complexities to be aware of to ensure the participant is well supported?Any additional information or complexities to be aware of to ensure the participant is well
supported? SAFETY ISSUESFor the safety of staff, please outline if there are any safety considerations to be aware of
when visiting the client in their home:Is anyone at the property known to be aggressive or violent? If so, will there be a support worker / support coordinator / carer present for the appointment, or would you recommend two therapists attend?Are you aware of there being firearms, weapons, sharps or other drug paraphernalia at the property?Are you aware of any occupant having infectious disease (e.g., flu symptoms, gastro, MRSA)?Are you aware of any pets/animals in the premises? If so, please describe. Save & Continue Δ
- [OT Referral Form Mount Isa](https://www.healthfirstgroup.com.au/ot-referral-form-mount-isa/): OT Referral Form Mount Isa CommentsThis field is for validation purposes and should be left unchanged.REFERRER DETAILSDate(Required) MM slash DD slash YYYY Name(Required)Email(Required) OrganizationContact Number(Required)CLIENT DETAILSClient Name(Required)Contact Number(Required)Client Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country D.O.B.Email(Required) Please tick any of the following that apply to the participant’s current situation: PBSP MHA ILO SDA SIL RatioDoes the participant require additional support to facilitate communication? e.g. interpreter, signer, etc.Preferred Method of Contact (SC/Direct/Alternative Contact)Who will sign the service agreement?(Required) Participant OPG Plan Nominee/EPOA Emergency Contact Details (Name, Number, Relationship)(Required)NDIS DETAILSNDIS No.(Required)Plan Dates(Required)Support Coordinator(Required)Email(Required) Plan Management Type(Required) Plan Managed Agency Managed Self-Managed Plan Management DetailsEmail(Required) Primary DisabilitySecondary DisabilitiesDoes the participant have any support / services in place?GPOrganisationPhoneEmail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Payment of AccountWho is responsible for paying the account? NDIS Portal and I authorise RTS to create a Service Booking for the hours nominated in a signed service agreement. Registered Plan Manager (please complete details below) Self (please complete details below) Name of Plan Management Organisation (if applicable):Which NDIS funding source should we be utilising? Core Funding Improved Daily Living Name of the person responsible for the accountPhoneEmail for invoices to be forwarded: REFERRAL FORMSERVICES REQUESTED Functional Capacity Assessment & NDIS Review Report Environment Assessment Occupational Support Profile & Report (not intended for NDIS plan reviews) Home and Living: S-I-L Assessment & S-I-L Report Home and Living: ILO AT Assessment & Letter of Support ONGOING THERAPY Routine Establishment Sensory Assessment & Sensory Modulation Plan Cognitive Assessment & Strategy Training Activities of Daily Living Training, Community & Life Skills Training DURATION OF SERVICE Assessment Report & Discharge Assessment Report & Ongoing Therapy Ongoing Therapy ADDITIONAL INFORMATIONIn your opinion, is the client best suited for one extended
2-hour assessment appointment or 2 x 1 hour appointment?
(Please consider the clients ability to maintain focus and
engagement) 1 x 2 hour 2 x 1 hour N/A – Ongoing Therapy MEDICAL HISTORYPlease provide a summary of the client’s Current AND Previous medical history: Please tick all the applicable boxes below and provide details: ABI Stroke Spinal cord injury Neurological condition Dementia Bipolar / Schizophrenia Disorder Depression / Anxiety Disorder Autism Spectrum Neurodevelopmental Disorder Intellectual Disability Other Mental Health Diagnosis Please provide detailed medical history belowHas the person being referred ever had, OR do they currently have, an infectious disease? If YES, please provide full details YES NO Details(Required)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 Interpreter required: YES NO Language(Required)Do you have any ethnic or religious beliefs you need us to be aware of? YES NO If yes, provide details(Required)Service Request - please provide details of the service you requireService Request - please provide details of the service you require Full OT Assessment Carer assessment and/or carer training Computer-Based Therapy – Clinic 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 below:(Required)Other services currently involved in therapy/treatment:i.e., Physiotherapist, Speech Therapist, NeuropsychologistI give Health First Group the authority to speak with any of my service providers during the period of support as agreed by all parties. YES NO REFERRAL FORMADDITIONAL INFORMATIONHas the participant ever received support from an Occupational Therapist? Any additional information or complexities to be aware of to ensure the participant is well supported?Any additional information or complexities to be aware of to ensure the participant is well
supported? SAFETY ISSUESFor the safety of staff, please outline if there are any safety considerations to be aware of
when visiting the client in their home:Is anyone at the property known to be aggressive or violent? If so, will there be a support worker / support coordinator / carer present for the appointment, or would you recommend two therapists attend?Are you aware of there being firearms, weapons, sharps or other drug paraphernalia at the property?Are you aware of any occupant having infectious disease (e.g., flu symptoms, gastro, MRSA)?Are you aware of any pets/animals in the premises? If so, please describe. Save & Continue Δ
- [OT Referral Form Cairns](https://www.healthfirstgroup.com.au/ot-referral-form-cairns/): OT Referral Form Cairns EmailThis field is for validation purposes and should be left unchanged.REFERRER DETAILSDate(Required) MM slash DD slash YYYY Name(Required)Email(Required) OrganizationContact Number(Required)CLIENT DETAILSClient Name(Required)Contact Number(Required)Client Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country D.O.B.Email(Required) Please tick any of the following that apply to the participant’s current situation: PBSP MHA ILO SDA SIL RatioDoes the participant require additional support to facilitate communication? e.g. interpreter, signer, etc.Preferred Method of Contact (SC/Direct/Alternative Contact)Who will sign the service agreement?(Required) Participant OPG Plan Nominee/EPOA Emergency Contact Details (Name, Number, Relationship)(Required)NDIS DETAILSNDIS No.(Required)Plan Dates(Required)Support Coordinator(Required)Email(Required) Plan Management Type(Required) Plan Managed Agency Managed Self-Managed Plan Management DetailsEmail(Required) Primary DisabilitySecondary DisabilitiesDoes the participant have any support / services in place?GPOrganisationPhoneEmail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Payment of AccountWho is responsible for paying the account? NDIS Portal and I authorise RTS to create a Service Booking for the hours nominated in a signed service agreement. Registered Plan Manager (please complete details below) Self (please complete details below) Name of Plan Management Organisation (if applicable):Which NDIS funding source should we be utilising? Core Funding Improved Daily Living Name of the person responsible for the accountPhoneEmail for invoices to be forwarded: REFERRAL FORMSERVICES REQUESTED Functional Capacity Assessment & NDIS Review Report Environment Assessment Occupational Support Profile & Report (not intended for NDIS plan reviews) Home and Living: S-I-L Assessment & S-I-L Report Home and Living: ILO AT Assessment & Letter of Support ONGOING THERAPY Routine Establishment Sensory Assessment & Sensory Modulation Plan Cognitive Assessment & Strategy Training Activities of Daily Living Training, Community & Life Skills Training DURATION OF SERVICE Assessment Report & Discharge Assessment Report & Ongoing Therapy Ongoing Therapy ADDITIONAL INFORMATIONIn your opinion, is the client best suited for one extended
2-hour assessment appointment or 2 x 1 hour appointment?
(Please consider the clients ability to maintain focus and
engagement) 1 x 2 hour 2 x 1 hour N/A – Ongoing Therapy MEDICAL HISTORYPlease provide a summary of the client’s Current AND Previous medical history: Please tick all the applicable boxes below and provide details: ABI Stroke Spinal cord injury Neurological condition Dementia Bipolar / Schizophrenia Disorder Depression / Anxiety Disorder Autism Spectrum Neurodevelopmental Disorder Intellectual Disability Other Mental Health Diagnosis Please provide detailed medical history belowHas the person being referred ever had, OR do they currently have, an infectious disease? If YES, please provide full details YES NO Details(Required)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 Interpreter required: YES NO Language(Required)Do you have any ethnic or religious beliefs you need us to be aware of? YES NO If yes, provide details(Required)Service Request - please provide details of the service you requireService Request - please provide details of the service you require Full OT Assessment Carer assessment and/or carer training Computer-Based Therapy – Clinic 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 below:(Required)Other services currently involved in therapy/treatment:i.e., Physiotherapist, Speech Therapist, NeuropsychologistI give Health First Group the authority to speak with any of my service providers during the period of support as agreed by all parties. YES NO REFERRAL FORMADDITIONAL INFORMATIONHas the participant ever received support from an Occupational Therapist? Any additional information or complexities to be aware of to ensure the participant is well supported?Any additional information or complexities to be aware of to ensure the participant is well
supported? SAFETY ISSUESFor the safety of staff, please outline if there are any safety considerations to be aware of
when visiting the client in their home:Is anyone at the property known to be aggressive or violent? If so, will there be a support worker / support coordinator / carer present for the appointment, or would you recommend two therapists attend?Are you aware of there being firearms, weapons, sharps or other drug paraphernalia at the property?Are you aware of any occupant having infectious disease (e.g., flu symptoms, gastro, MRSA)?Are you aware of any pets/animals in the premises? If so, please describe. Save & Continue Δ
- [OT Referral Form Bunbury](https://www.healthfirstgroup.com.au/ot-referral-form-bunbury/): OT Referral Form Bunbury LinkedInThis field is for validation purposes and should be left unchanged.REFERRER DETAILSDate(Required) MM slash DD slash YYYY Name(Required)Email(Required) OrganizationContact Number(Required)CLIENT DETAILSClient Name(Required)Contact Number(Required)Client Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country D.O.B.Email(Required) Please tick any of the following that apply to the participant’s current situation: PBSP MHA ILO SDA SIL RatioDoes the participant require additional support to facilitate communication? e.g. interpreter, signer, etc.Preferred Method of Contact (SC/Direct/Alternative Contact)Who will sign the service agreement?(Required) Participant OPG Plan Nominee/EPOA Emergency Contact Details (Name, Number, Relationship)(Required)NDIS DETAILSNDIS No.(Required)Plan Dates(Required)Support Coordinator(Required)Email(Required) Plan Management Type(Required) Plan Managed Agency Managed Self-Managed Plan Management DetailsEmail(Required) Primary DisabilitySecondary DisabilitiesDoes the participant have any support / services in place?GPOrganisationPhoneEmail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Payment of AccountWho is responsible for paying the account? NDIS Portal and I authorise RTS to create a Service Booking for the hours nominated in a signed service agreement. Registered Plan Manager (please complete details below) Self (please complete details below) Name of Plan Management Organisation (if applicable):Which NDIS funding source should we be utilising? Core Funding Improved Daily Living Name of the person responsible for the accountPhoneEmail for invoices to be forwarded: REFERRAL FORMSERVICES REQUESTED Functional Capacity Assessment & NDIS Review Report Environment Assessment Occupational Support Profile & Report (not intended for NDIS plan reviews) Home and Living: S-I-L Assessment & S-I-L Report Home and Living: ILO AT Assessment & Letter of Support ONGOING THERAPY Routine Establishment Sensory Assessment & Sensory Modulation Plan Cognitive Assessment & Strategy Training Activities of Daily Living Training, Community & Life Skills Training DURATION OF SERVICE Assessment Report & Discharge Assessment Report & Ongoing Therapy Ongoing Therapy ADDITIONAL INFORMATIONIn your opinion, is the client best suited for one extended
2-hour assessment appointment or 2 x 1 hour appointment?
(Please consider the clients ability to maintain focus and
engagement) 1 x 2 hour 2 x 1 hour N/A – Ongoing Therapy MEDICAL HISTORYPlease provide a summary of the client’s Current AND Previous medical history: Please tick all the applicable boxes below and provide details: ABI Stroke Spinal cord injury Neurological condition Dementia Bipolar / Schizophrenia Disorder Depression / Anxiety Disorder Autism Spectrum Neurodevelopmental Disorder Intellectual Disability Other Mental Health Diagnosis Please provide detailed medical history belowHas the person being referred ever had, OR do they currently have, an infectious disease? If YES, please provide full details YES NO Details(Required)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 Interpreter required: YES NO Language(Required)Do you have any ethnic or religious beliefs you need us to be aware of? YES NO If yes, provide details(Required)Service Request - please provide details of the service you requireService Request - please provide details of the service you require Full OT Assessment Carer assessment and/or carer training Computer-Based Therapy – Clinic 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 below:(Required)Other services currently involved in therapy/treatment:i.e., Physiotherapist, Speech Therapist, NeuropsychologistI give Health First Group the authority to speak with any of my service providers during the period of support as agreed by all parties. YES NO REFERRAL FORMADDITIONAL INFORMATIONHas the participant ever received support from an Occupational Therapist? Any additional information or complexities to be aware of to ensure the participant is well supported?Any additional information or complexities to be aware of to ensure the participant is well
supported? SAFETY ISSUESFor the safety of staff, please outline if there are any safety considerations to be aware of
when visiting the client in their home:Is anyone at the property known to be aggressive or violent? If so, will there be a support worker / support coordinator / carer present for the appointment, or would you recommend two therapists attend?Are you aware of there being firearms, weapons, sharps or other drug paraphernalia at the property?Are you aware of any occupant having infectious disease (e.g., flu symptoms, gastro, MRSA)?Are you aware of any pets/animals in the premises? If so, please describe. Save & Continue Δ
- [OT Referral Form Alice Springs](https://www.healthfirstgroup.com.au/ot-referral-form-alice-springs/): OT Referral Form Alice Springs FacebookThis field is for validation purposes and should be left unchanged.REFERRER DETAILSDate(Required) MM slash DD slash YYYY Name(Required)Email(Required) OrganizationContact Number(Required)CLIENT DETAILSClient Name(Required)Contact Number(Required)Client Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country D.O.B.Email(Required) Please tick any of the following that apply to the participant’s current situation: PBSP MHA ILO SDA SIL RatioDoes the participant require additional support to facilitate communication? e.g. interpreter, signer, etc.Preferred Method of Contact (SC/Direct/Alternative Contact)Who will sign the service agreement?(Required) Participant OPG Plan Nominee/EPOA Emergency Contact Details (Name, Number, Relationship)(Required)NDIS DETAILSNDIS No.(Required)Plan Dates(Required)Support Coordinator(Required)Email(Required) Plan Management Type(Required) Plan Managed Agency Managed Self-Managed Plan Management DetailsEmail(Required) Primary DisabilitySecondary DisabilitiesDoes the participant have any support / services in place?GPOrganisationPhoneEmail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Payment of AccountWho is responsible for paying the account? NDIS Portal and I authorise RTS to create a Service Booking for the hours nominated in a signed service agreement. Registered Plan Manager (please complete details below) Self (please complete details below) Name of Plan Management Organisation (if applicable):Which NDIS funding source should we be utilising? Core Funding Improved Daily Living Name of the person responsible for the accountPhoneEmail for invoices to be forwarded: REFERRAL FORMSERVICES REQUESTED Functional Capacity Assessment & NDIS Review Report Environment Assessment Occupational Support Profile & Report (not intended for NDIS plan reviews) Home and Living: S-I-L Assessment & S-I-L Report Home and Living: ILO AT Assessment & Letter of Support ONGOING THERAPY Routine Establishment Sensory Assessment & Sensory Modulation Plan Cognitive Assessment & Strategy Training Activities of Daily Living Training, Community & Life Skills Training DURATION OF SERVICE Assessment Report & Discharge Assessment Report & Ongoing Therapy Ongoing Therapy ADDITIONAL INFORMATIONIn your opinion, is the client best suited for one extended
2-hour assessment appointment or 2 x 1 hour appointment?
(Please consider the clients ability to maintain focus and
engagement) 1 x 2 hour 2 x 1 hour N/A – Ongoing Therapy MEDICAL HISTORYPlease provide a summary of the client’s Current AND Previous medical history: Please tick all the applicable boxes below and provide details: ABI Stroke Spinal cord injury Neurological condition Dementia Bipolar / Schizophrenia Disorder Depression / Anxiety Disorder Autism Spectrum Neurodevelopmental Disorder Intellectual Disability Other Mental Health Diagnosis Please provide detailed medical history belowHas the person being referred ever had, OR do they currently have, an infectious disease? If YES, please provide full details YES NO Details(Required)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 Interpreter required: YES NO Language(Required)Do you have any ethnic or religious beliefs you need us to be aware of? YES NO If yes, provide details(Required)Service Request - please provide details of the service you requireService Request - please provide details of the service you require Full OT Assessment Carer assessment and/or carer training Computer-Based Therapy – Clinic 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 below:(Required)Other services currently involved in therapy/treatment:i.e., Physiotherapist, Speech Therapist, NeuropsychologistI give Health First Group the authority to speak with any of my service providers during the period of support as agreed by all parties. YES NO REFERRAL FORMADDITIONAL INFORMATIONHas the participant ever received support from an Occupational Therapist? Any additional information or complexities to be aware of to ensure the participant is well supported?Any additional information or complexities to be aware of to ensure the participant is well
supported? SAFETY ISSUESFor the safety of staff, please outline if there are any safety considerations to be aware of
when visiting the client in their home:Is anyone at the property known to be aggressive or violent? If so, will there be a support worker / support coordinator / carer present for the appointment, or would you recommend two therapists attend?Are you aware of there being firearms, weapons, sharps or other drug paraphernalia at the property?Are you aware of any occupant having infectious disease (e.g., flu symptoms, gastro, MRSA)?Are you aware of any pets/animals in the premises? If so, please describe. Save & Continue Δ
- [OT Referral Form Riverland](https://www.healthfirstgroup.com.au/ot-referral-form-riverland/): OT Referral Form Riverland FacebookThis field is for validation purposes and should be left unchanged.REFERRER DETAILSDate(Required) MM slash DD slash YYYY Name(Required)Email(Required) OrganizationContact Number(Required)CLIENT DETAILSClient Name(Required)Contact Number(Required)Client Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country D.O.B.Email(Required) Please tick any of the following that apply to the participant’s current situation: PBSP MHA ILO SDA SIL RatioDoes the participant require additional support to facilitate communication? e.g. interpreter, signer, etc.Preferred Method of Contact (SC/Direct/Alternative Contact)Who will sign the service agreement?(Required) Participant OPG Plan Nominee/EPOA Emergency Contact Details (Name, Number, Relationship)(Required)NDIS DETAILSNDIS No.(Required)Plan Dates(Required)Support Coordinator(Required)Email(Required) Plan Management Type(Required) Plan Managed Agency Managed Self-Managed Plan Management DetailsEmail(Required) Primary DisabilitySecondary DisabilitiesDoes the participant have any support / services in place?GPOrganisationPhoneEmail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Payment of AccountWho is responsible for paying the account? NDIS Portal and I authorise RTS to create a Service Booking for the hours nominated in a signed service agreement. Registered Plan Manager (please complete details below) Self (please complete details below) Name of Plan Management Organisation (if applicable):Which NDIS funding source should we be utilising? Core Funding Improved Daily Living Name of the person responsible for the accountPhoneEmail for invoices to be forwarded: REFERRAL FORMSERVICES REQUESTED Functional Capacity Assessment & NDIS Review Report Environment Assessment Occupational Support Profile & Report (not intended for NDIS plan reviews) Home and Living: S-I-L Assessment & S-I-L Report Home and Living: ILO AT Assessment & Letter of Support ONGOING THERAPY Routine Establishment Sensory Assessment & Sensory Modulation Plan Cognitive Assessment & Strategy Training Activities of Daily Living Training, Community & Life Skills Training DURATION OF SERVICE Assessment Report & Discharge Assessment Report & Ongoing Therapy Ongoing Therapy ADDITIONAL INFORMATIONIn your opinion, is the client best suited for one extended
2-hour assessment appointment or 2 x 1 hour appointment?
(Please consider the clients ability to maintain focus and
engagement) 1 x 2 hour 2 x 1 hour N/A – Ongoing Therapy MEDICAL HISTORYPlease provide a summary of the client’s Current AND Previous medical history: Please tick all the applicable boxes below and provide details: ABI Stroke Spinal cord injury Neurological condition Dementia Bipolar / Schizophrenia Disorder Depression / Anxiety Disorder Autism Spectrum Neurodevelopmental Disorder Intellectual Disability Other Mental Health Diagnosis Please provide detailed medical history belowHas the person being referred ever had, OR do they currently have, an infectious disease? If YES, please provide full details YES NO Details(Required)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 Interpreter required: YES NO Language(Required)Do you have any ethnic or religious beliefs you need us to be aware of? YES NO If yes, provide details(Required)Service Request - please provide details of the service you requireService Request - please provide details of the service you require Full OT Assessment Carer assessment and/or carer training Computer-Based Therapy – Clinic 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 below:(Required)Other services currently involved in therapy/treatment:i.e., Physiotherapist, Speech Therapist, NeuropsychologistI give Health First Group the authority to speak with any of my service providers during the period of support as agreed by all parties. YES NO REFERRAL FORMADDITIONAL INFORMATIONHas the participant ever received support from an Occupational Therapist? Any additional information or complexities to be aware of to ensure the participant is well supported?Any additional information or complexities to be aware of to ensure the participant is well
supported? SAFETY ISSUESFor the safety of staff, please outline if there are any safety considerations to be aware of
when visiting the client in their home:Is anyone at the property known to be aggressive or violent? If so, will there be a support worker / support coordinator / carer present for the appointment, or would you recommend two therapists attend?Are you aware of there being firearms, weapons, sharps or other drug paraphernalia at the property?Are you aware of any occupant having infectious disease (e.g., flu symptoms, gastro, MRSA)?Are you aware of any pets/animals in the premises? If so, please describe. Save & Continue Δ
- [OT Referral Form Maryborough](https://www.healthfirstgroup.com.au/ot-referral-form-maryborough/): OT Referral Form Maryborough LinkedInThis field is for validation purposes and should be left unchanged.REFERRER DETAILSDate(Required) MM slash DD slash YYYY Name(Required)Email(Required) OrganizationContact Number(Required)CLIENT DETAILSClient Name(Required)Contact Number(Required)Client Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country D.O.B.Email(Required) Please tick any of the following that apply to the participant’s current situation: PBSP MHA ILO SDA SIL RatioDoes the participant require additional support to facilitate communication? e.g. interpreter, signer, etc.Preferred Method of Contact (SC/Direct/Alternative Contact)Who will sign the service agreement?(Required) Participant OPG Plan Nominee/EPOA Emergency Contact Details (Name, Number, Relationship)(Required)NDIS DETAILSNDIS No.(Required)Plan Dates(Required)Support Coordinator(Required)Email(Required) Plan Management Type(Required) Plan Managed Agency Managed Self-Managed Plan Management DetailsEmail(Required) Primary DisabilitySecondary DisabilitiesDoes the participant have any support / services in place?GPOrganisationPhoneEmail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Payment of AccountWho is responsible for paying the account? NDIS Portal and I authorise RTS to create a Service Booking for the hours nominated in a signed service agreement. Registered Plan Manager (please complete details below) Self (please complete details below) Name of Plan Management Organisation (if applicable):Which NDIS funding source should we be utilising? Core Funding Improved Daily Living Name of the person responsible for the accountPhoneEmail for invoices to be forwarded: REFERRAL FORMSERVICES REQUESTED Functional Capacity Assessment & NDIS Review Report Environment Assessment Occupational Support Profile & Report (not intended for NDIS plan reviews) Home and Living: S-I-L Assessment & S-I-L Report Home and Living: ILO AT Assessment & Letter of Support ONGOING THERAPY Routine Establishment Sensory Assessment & Sensory Modulation Plan Cognitive Assessment & Strategy Training Activities of Daily Living Training, Community & Life Skills Training DURATION OF SERVICE Assessment Report & Discharge Assessment Report & Ongoing Therapy Ongoing Therapy ADDITIONAL INFORMATIONIn your opinion, is the client best suited for one extended
2-hour assessment appointment or 2 x 1 hour appointment?
(Please consider the clients ability to maintain focus and
engagement) 1 x 2 hour 2 x 1 hour N/A – Ongoing Therapy MEDICAL HISTORYPlease provide a summary of the client’s Current AND Previous medical history: Please tick all the applicable boxes below and provide details: ABI Stroke Spinal cord injury Neurological condition Dementia Bipolar / Schizophrenia Disorder Depression / Anxiety Disorder Autism Spectrum Neurodevelopmental Disorder Intellectual Disability Other Mental Health Diagnosis Please provide detailed medical history belowHas the person being referred ever had, OR do they currently have, an infectious disease? If YES, please provide full details YES NO Details(Required)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 Interpreter required: YES NO Language(Required)Do you have any ethnic or religious beliefs you need us to be aware of? YES NO If yes, provide details(Required)Service Request - please provide details of the service you requireService Request - please provide details of the service you require Full OT Assessment Carer assessment and/or carer training Computer-Based Therapy – Clinic 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 below:(Required)Other services currently involved in therapy/treatment:i.e., Physiotherapist, Speech Therapist, NeuropsychologistI give Health First Group the authority to speak with any of my service providers during the period of support as agreed by all parties. YES NO REFERRAL FORMADDITIONAL INFORMATIONHas the participant ever received support from an Occupational Therapist? Any additional information or complexities to be aware of to ensure the participant is well supported?Any additional information or complexities to be aware of to ensure the participant is well
supported? SAFETY ISSUESFor the safety of staff, please outline if there are any safety considerations to be aware of
when visiting the client in their home:Is anyone at the property known to be aggressive or violent? If so, will there be a support worker / support coordinator / carer present for the appointment, or would you recommend two therapists attend?Are you aware of there being firearms, weapons, sharps or other drug paraphernalia at the property?Are you aware of any occupant having infectious disease (e.g., flu symptoms, gastro, MRSA)?Are you aware of any pets/animals in the premises? If so, please describe. Save & Continue Δ
- [OT Referral Form Launceston](https://www.healthfirstgroup.com.au/ot-referral-form-launceston/): OT Referral Form Launceston CommentsThis field is for validation purposes and should be left unchanged.REFERRER DETAILSDate(Required) MM slash DD slash YYYY Name(Required)Email(Required) OrganizationContact Number(Required)CLIENT DETAILSClient Name(Required)Contact Number(Required)Client Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country D.O.B.Email(Required) Please tick any of the following that apply to the participant’s current situation: PBSP MHA ILO SDA SIL RatioDoes the participant require additional support to facilitate communication? e.g. interpreter, signer, etc.Preferred Method of Contact (SC/Direct/Alternative Contact)Who will sign the service agreement?(Required) Participant OPG Plan Nominee/EPOA Emergency Contact Details (Name, Number, Relationship)(Required)NDIS DETAILSNDIS No.(Required)Plan Dates(Required)Support Coordinator(Required)Email(Required) Plan Management Type(Required) Plan Managed Agency Managed Self-Managed Plan Management DetailsEmail(Required) Primary DisabilitySecondary DisabilitiesDoes the participant have any support / services in place?GPOrganisationPhoneEmail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Payment of AccountWho is responsible for paying the account? NDIS Portal and I authorise RTS to create a Service Booking for the hours nominated in a signed service agreement. Registered Plan Manager (please complete details below) Self (please complete details below) Name of Plan Management Organisation (if applicable):Which NDIS funding source should we be utilising? Core Funding Improved Daily Living Name of the person responsible for the accountPhoneEmail for invoices to be forwarded: REFERRAL FORMSERVICES REQUESTED Functional Capacity Assessment & NDIS Review Report Environment Assessment Occupational Support Profile & Report (not intended for NDIS plan reviews) Home and Living: S-I-L Assessment & S-I-L Report Home and Living: ILO AT Assessment & Letter of Support ONGOING THERAPY Routine Establishment Sensory Assessment & Sensory Modulation Plan Cognitive Assessment & Strategy Training Activities of Daily Living Training, Community & Life Skills Training DURATION OF SERVICE Assessment Report & Discharge Assessment Report & Ongoing Therapy Ongoing Therapy ADDITIONAL INFORMATIONIn your opinion, is the client best suited for one extended
2-hour assessment appointment or 2 x 1 hour appointment?
(Please consider the clients ability to maintain focus and
engagement) 1 x 2 hour 2 x 1 hour N/A – Ongoing Therapy MEDICAL HISTORYPlease provide a summary of the client’s Current AND Previous medical history: Please tick all the applicable boxes below and provide details: ABI Stroke Spinal cord injury Neurological condition Dementia Bipolar / Schizophrenia Disorder Depression / Anxiety Disorder Autism Spectrum Neurodevelopmental Disorder Intellectual Disability Other Mental Health Diagnosis Please provide detailed medical history belowHas the person being referred ever had, OR do they currently have, an infectious disease? If YES, please provide full details YES NO Details(Required)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 Interpreter required: YES NO Language(Required)Do you have any ethnic or religious beliefs you need us to be aware of? YES NO If yes, provide details(Required)Service Request - please provide details of the service you requireService Request - please provide details of the service you require Full OT Assessment Carer assessment and/or carer training Computer-Based Therapy – Clinic 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 below:(Required)Other services currently involved in therapy/treatment:i.e., Physiotherapist, Speech Therapist, NeuropsychologistI give Health First Group the authority to speak with any of my service providers during the period of support as agreed by all parties. YES NO REFERRAL FORMADDITIONAL INFORMATIONHas the participant ever received support from an Occupational Therapist? Any additional information or complexities to be aware of to ensure the participant is well supported?Any additional information or complexities to be aware of to ensure the participant is well
supported? SAFETY ISSUESFor the safety of staff, please outline if there are any safety considerations to be aware of
when visiting the client in their home:Is anyone at the property known to be aggressive or violent? If so, will there be a support worker / support coordinator / carer present for the appointment, or would you recommend two therapists attend?Are you aware of there being firearms, weapons, sharps or other drug paraphernalia at the property?Are you aware of any occupant having infectious disease (e.g., flu symptoms, gastro, MRSA)?Are you aware of any pets/animals in the premises? If so, please describe. Save & Continue Δ
- [OT Referral Form](https://www.healthfirstgroup.com.au/ot-referral-form/): OT Referral Form LinkedInThis field is for validation purposes and should be left unchanged.REFERRER DETAILSDate(Required) MM slash DD slash YYYY Name(Required)Email(Required) OrganizationContact Number(Required)CLIENT DETAILSClient Name(Required)Contact Number(Required)Client Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country D.O.B.Email(Required) Please tick any of the following that apply to the participant’s current situation: PBSP MHA ILO SDA SIL RatioDoes the participant require additional support to facilitate communication? e.g. interpreter, signer, etc.Preferred Method of Contact (SC/Direct/Alternative Contact)Who will sign the service agreement?(Required) Participant OPG Plan Nominee/EPOA Emergency Contact Details (Name, Number, Relationship)(Required)NDIS DETAILSNDIS No.(Required)Plan Dates(Required)Support Coordinator(Required)Email(Required) Plan Management Type(Required) Plan Managed Agency Managed Self-Managed Plan Management DetailsEmail(Required) Primary DisabilitySecondary DisabilitiesDoes the participant have any support / services in place?GPOrganisationPhoneEmail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Payment of AccountWho is responsible for paying the account? NDIS Portal and I authorise RTS to create a Service Booking for the hours nominated in a signed service agreement. Registered Plan Manager (please complete details below) Self (please complete details below) Name of Plan Management Organisation (if applicable):Which NDIS funding source should we be utilising? Core Funding Improved Daily Living Name of the person responsible for the accountPhoneEmail for invoices to be forwarded: REFERRAL FORMSERVICES REQUESTED Functional Capacity Assessment & NDIS Review Report Environment Assessment Occupational Support Profile & Report (not intended for NDIS plan reviews) Home and Living: S-I-L Assessment & S-I-L Report Home and Living: ILO AT Assessment & Letter of Support ONGOING THERAPY Routine Establishment Sensory Assessment & Sensory Modulation Plan Cognitive Assessment & Strategy Training Activities of Daily Living Training, Community & Life Skills Training DURATION OF SERVICE Assessment Report & Discharge Assessment Report & Ongoing Therapy Ongoing Therapy ADDITIONAL INFORMATIONIn your opinion, is the client best suited for one extended
2-hour assessment appointment or 2 x 1 hour appointment?
(Please consider the clients ability to maintain focus and
engagement) 1 x 2 hour 2 x 1 hour N/A – Ongoing Therapy MEDICAL HISTORYPlease provide a summary of the client’s Current AND Previous medical history: Please tick all the applicable boxes below and provide details: ABI Stroke Spinal cord injury Neurological condition Dementia Bipolar / Schizophrenia Disorder Depression / Anxiety Disorder Autism Spectrum Neurodevelopmental Disorder Intellectual Disability Other Mental Health Diagnosis Please provide detailed medical history belowHas the person being referred ever had, OR do they currently have, an infectious disease? If YES, please provide full details YES NO Details(Required)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 Interpreter required: YES NO Language(Required)Do you have any ethnic or religious beliefs you need us to be aware of? YES NO If yes, provide details(Required)Service Request - please provide details of the service you requireService Request - please provide details of the service you require Full OT Assessment Carer assessment and/or carer training Computer-Based Therapy – Clinic 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 below:(Required)Other services currently involved in therapy/treatment:i.e., Physiotherapist, Speech Therapist, NeuropsychologistI give Health First Group the authority to speak with any of my service providers during the period of support as agreed by all parties. YES NO REFERRAL FORMADDITIONAL INFORMATIONHas the participant ever received support from an Occupational Therapist? Any additional information or complexities to be aware of to ensure the participant is well supported?Any additional information or complexities to be aware of to ensure the participant is well
supported? SAFETY ISSUESFor the safety of staff, please outline if there are any safety considerations to be aware of
when visiting the client in their home:Is anyone at the property known to be aggressive or violent? If so, will there be a support worker / support coordinator / carer present for the appointment, or would you recommend two therapists attend?Are you aware of there being firearms, weapons, sharps or other drug paraphernalia at the property?Are you aware of any occupant having infectious disease (e.g., flu symptoms, gastro, MRSA)?Are you aware of any pets/animals in the premises? If so, please describe. Save & Continue Δ
- [Medico-legal Assessment & Report Writing](https://www.healthfirstgroup.com.au/medico-legal-assessment-report-writing/)
- [Life Skills Training](https://www.healthfirstgroup.com.au/life-skills-training/)
- [Ergonomic Assessments](https://www.healthfirstgroup.com.au/ergonomic-assessments/)
- [Falls Prevention Education](https://www.healthfirstgroup.com.au/falls-prevention-education/)
- [Paediatrics](https://www.healthfirstgroup.com.au/paediatrics/)
- [Assistive Technology](https://www.healthfirstgroup.com.au/assistive-technology/)
- [Sensory Assessments](https://www.healthfirstgroup.com.au/sensory-assessments/)
- [Home Modifications](https://www.healthfirstgroup.com.au/home-modifications/)
- [Pain Management](https://www.healthfirstgroup.com.au/pain-management/)
- [Home Safety Assessments](https://www.healthfirstgroup.com.au/home-safety-assessments/)
- [SDA Assessments](https://www.healthfirstgroup.com.au/sda-assessments/)
- [Gold Coast](https://www.healthfirstgroup.com.au/locations/queensland/gold-coast-occupational-therapy/): Health First Gold Coast offers experienced Occupational Therapists ready to support you when you need them.Our Occupational Therapy clinic is conveniently located in Robina, with on-site parking available. We are NDIS registered and just a short drive from the Gold Coast Hinterland.
- [Occupational Therapy Gold Coast](https://www.healthfirstgroup.com.au/services/allied-health/occupational-therapy-gold-coast/)
- [Occupational Therapy Cairns](https://www.healthfirstgroup.com.au/services/allied-health/occupational-therapy-cairns/)
- [Occupational Therapy Barmera](https://www.healthfirstgroup.com.au/services/allied-health/occupational-therapy-barmera/)
- [Occupational Therapy Renmark](https://www.healthfirstgroup.com.au/services/allied-health/occupational-therapy-renmark/)
- [Occupational Therapy Albany](https://www.healthfirstgroup.com.au/services/allied-health/occupational-therapy-albany/)
- [Occupational Therapy Rockhampton](https://www.healthfirstgroup.com.au/services/allied-health/occupational-therapy-rockhampton/)
- [Occupational Therapy Shepparton](https://www.healthfirstgroup.com.au/services/allied-health/occupational-therapy-shepparton/)
- [Occupational Therapy Maryborough](https://www.healthfirstgroup.com.au/services/allied-health/occupational-therapy-maryborough/)
- [Occupational Therapy Alice Springs](https://www.healthfirstgroup.com.au/services/allied-health/occupational-therapy-alice-springs/)
- [Occupational Therapy Bundaberg](https://www.healthfirstgroup.com.au/services/allied-health/occupational-therapy-bundaberg/)
- [Occupational Therapy Gladstone](https://www.healthfirstgroup.com.au/services/allied-health/occupational-therapy-gladstone/)
- [Occupational Therapy Launceston](https://www.healthfirstgroup.com.au/services/allied-health/occupational-therapy-launceston/)
- [Occupational Therapy Mount Isa](https://www.healthfirstgroup.com.au/services/allied-health/occupational-therapy-mount-isa/)
- [Occupational Therapy Mackay](https://www.healthfirstgroup.com.au/services/allied-health/occupational-therapy-mackay/)
- [Occupational Therapy Bunbury](https://www.healthfirstgroup.com.au/services/allied-health/occupational-therapy-bunbury/)
- [Psychologists in Bundaberg](https://www.healthfirstgroup.com.au/psychologist-in-bundaberg/): Finding a trustworthy psychologist in Bundaberg is crucial for addressing mental health challenges and achieving personal well-being. Our Health First Group Psychologists are dedicated to providing high-quality care to individuals and families in the Bundaberg area.
- [Occupational Therapy – Riverland](https://www.healthfirstgroup.com.au/services/allied-health/occupational-therapy-riverland/)
- [Functional Capacity Assessments](https://www.healthfirstgroup.com.au/functional-capacity-assessments/)
- [Podiatrists in Gladstone](https://www.healthfirstgroup.com.au/podiatrists-in-gladstone/): At Health First Gladstone, we specialise in providing expert podiatry care to address all your foot and ankle needs. Whether you're dealing with chronic foot pain, sports injuries, or any other podiatric condition, our experienced podiatrists are here to help you achieve optimal health and comfort. 
- [Psychologists in Gladstone](https://www.healthfirstgroup.com.au/psychologist-in-gladstone/): Finding a trustworthy psychologist in Gladstone is crucial for addressing mental health challenges and achieving personal well-being. Our Health First Group Psychologists are dedicated to providing high-quality care to individuals and families in the Gladstone area.
- [Psychologist in Maryborough](https://www.healthfirstgroup.com.au/psychologist-in-maryborough/): We provide services to the Maryborough area and its surrounding suburbs, including Granville, Baddow, Boonooroo Plains, Maryborough West, Walkers Point, Tinana, and Grahams Creek.
- [Psychologist in Hervey Bay](https://www.healthfirstgroup.com.au/psychologist-in-hervey-bay/): Here at Health First Group, we prioritise your mental well-being. Our psychologists in Hervey Bay are dedicated to providing exceptional mental health care, further enhancing our comprehensive psychology services.
- [Crookwell](https://www.healthfirstgroup.com.au/locations/new-south-wales/crookwell/)
- [Psychology and Psychotherapy Services](https://www.healthfirstgroup.com.au/services/psychology-and-psychotherapy-services/)
- [Berri](https://www.healthfirstgroup.com.au/locations/south-australia/berri-physio/)
- [Men’s Health](https://www.healthfirstgroup.com.au/services/mens-health/)
- [Massage](https://www.healthfirstgroup.com.au/services/massage/)
- [Tasmania](https://www.healthfirstgroup.com.au/locations/tasmania/)
- [Launceston](https://www.healthfirstgroup.com.au/locations/tasmania/launceston-physio/)
- [Maryborough Free Initial Assessment](https://www.healthfirstgroup.com.au/maryborough-free-initial-assessment/)
- [Shepparton Free Initial Assessment](https://www.healthfirstgroup.com.au/shepparton-free-initial-assessment/)
- [Rockhampton Free Initial Assessment](https://www.healthfirstgroup.com.au/rockhampton-free-initial-assessment/)
- [Mount Isa Free Initial Assessment](https://www.healthfirstgroup.com.au/mount-isa-free-initial-assessment/)
- [Mackay Free Initial Assessment](https://www.healthfirstgroup.com.au/mackay-free-initial-assessment/)
- [Karratha Free Initial Assessment](https://www.healthfirstgroup.com.au/karratha-free-initial-assessment/)
- [Kalgoorlie Free Initial Assessment](https://www.healthfirstgroup.com.au/kalgoorlie-free-initial-assessment/)
- [Hurstville Free Initial Assessment](https://www.healthfirstgroup.com.au/hurstville-free-initial-assessment/)
- [Hervey Bay Free Initial Assessment](https://www.healthfirstgroup.com.au/hervey-bay-free-initial-assessment/)
- [Gold Coast Free Initial Assessment](https://www.healthfirstgroup.com.au/gold-coast-free-initial-assessment/)
- [Cairns Free Initial Assessment](https://www.healthfirstgroup.com.au/cairns-free-initial-assessment/)
- [Bunbury Free Initial Assessment](https://www.healthfirstgroup.com.au/bunbury-free-initial-assessment/)
- [Alice Springs Free Initial Assessment](https://www.healthfirstgroup.com.au/alice-springs-free-initial-assessment/)
- [Albany Free Initial Assessment](https://www.healthfirstgroup.com.au/albany-free-initial-assessment/)
- [Meet The Physio](https://www.healthfirstgroup.com.au/ndis-obligation-free/)
- [Renmark](https://www.healthfirstgroup.com.au/locations/south-australia/renmark-physio/)
- [Barmera](https://www.healthfirstgroup.com.au/locations/south-australia/barmera-physio/)
- [Waikerie](https://www.healthfirstgroup.com.au/locations/south-australia/waikerie-physio/)
- [South Australia](https://www.healthfirstgroup.com.au/locations/south-australia/)
- [Gladstone](https://www.healthfirstgroup.com.au/locations/queensland/gladstone-physio/)
- [Psychology](https://www.healthfirstgroup.com.au/services/psychology/)
- [Goulburn Free Initial Assessment](https://www.healthfirstgroup.com.au/goulburn-free-initial-assessment/)
- [Bundaberg Free Initial Assessment](https://www.healthfirstgroup.com.au/bundaberg-free-assessment/)
- [TMJ](https://www.healthfirstgroup.com.au/tmj/)
- [Vertigo](https://www.healthfirstgroup.com.au/vertigo/)
- [Wrist and Hand Pain](https://www.healthfirstgroup.com.au/wrist-and-hand-pain/)
- [Whiplash](https://www.healthfirstgroup.com.au/whiplash/)
- [Shoulder Pain](https://www.healthfirstgroup.com.au/shoulder-pain/)
- [Shin Splints](https://www.healthfirstgroup.com.au/shin-splints/)
- [Sciatica](https://www.healthfirstgroup.com.au/sciatica/)
- [Neck Pain](https://www.healthfirstgroup.com.au/neck-pain/)
- [Lower Limb Pain](https://www.healthfirstgroup.com.au/lower-limb-pain/): Lower limb pain is very common. It often occurs as a result of sporting injuries, work related injuries, or everyday use.
- [Knee Pain](https://www.healthfirstgroup.com.au/knee-pain/)
- [Hip Pain](https://www.healthfirstgroup.com.au/hip-pain/)
- [Headache](https://www.healthfirstgroup.com.au/headache/)
- [Elbow Pain](https://www.healthfirstgroup.com.au/elbow-pain/)
- [Foot Complaints](https://www.healthfirstgroup.com.au/foot-complaints/): Health First Group strives to relieve you from physiological problems by not only providing the best physio therapy, but also through sharing valuable insight into the problem. Please read on to learn about the different types of foot complaints
- [Ankle and Foot Pain](https://www.healthfirstgroup.com.au/ankle-and-foot-pain/): All injuries are treated by our physiotherapists at Health First Group. Don’t suffer from your pain any longer, and make an appointment to alleviate your pain.
- [Conditions](https://www.healthfirstgroup.com.au/conditions/)
- [50% Off Shockwave Therapy](https://www.healthfirstgroup.com.au/services/shockwave-bunbury/)
- [Physiotherapy for Women’s Health](https://www.healthfirstgroup.com.au/services/womens-health/)
- [Hervey Bay](https://www.healthfirstgroup.com.au/locations/queensland/hervey-bay-physio/)
- [Hurstville](https://www.healthfirstgroup.com.au/locations/new-south-wales/hurstville-physio/): Pages
- [Elevate Your Movement with Gaitscan Technology](https://www.healthfirstgroup.com.au/services/gaitscan/)
- [Dry Needling Deal](https://www.healthfirstgroup.com.au/services/dry-needling-promo/)