We welcome your referral for our community-based adult neuro services of Occupational Therapy, Physiotherapy and Speech Pathology.
Our friendly and helpful referral team are always happy to discuss you or your client’s allied health intervention needs.

Simply complete our online referral form below and we will contact you within 5 business days to complete the process.

If you need assistance with your referral, please call our client referral team between 8:30am and 5pm (Melbourne time) on  (03) 9885 2533.

Please complete all fields below

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Client Details

Please provide information about the person you are referring for our services.

Name *

First

Last

Date Of Birth *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Accommodation Type *Private homeSupported Disability Accommodation (SDA)Medium Term Accommodation (MTA)Aged CareOther

Phone Number *

Email *

Referrer Details

Who should we contact regarding this referral?

Referrer Name *

First

Last

Referral Phone Number *

Referrer Email *

What is your relationship to the client? *I am the clientGuardianNext of kinSupport CoordinatorOther

Referral Information

Please provide details about the services you require.

Which services are you referring to? *

• Occupational Therapy
• Physiotherapy
• Speech Pathology

Diagnosis/Condition *

Please note as we are a community based neurological rehabilitation service, we are not able to accept referrals where the primary diagnosis is any of the following: Intellectual Disability, Autism Spectrum Disorder, or Psychosocial.

What is the reason for this referral? *

• Initial Occupational Therapy Assessment
• Occupational Therapy - Home Modifications
• Occupational Therapy - Equipment Assessment
• Occupational Therapy - Upper Limb Therapy
• Occupational Therapy - Functional Capacity Assessment
• Occupational Therapy - TAC Assessment
• Occupational Therapy - Cognitive Rehab
• Occupational Therapy - Driving Assessment
• Occupational Therapy - Other
• Initial Physiotherapy Assessment
• Physiotherapy - Home Exercise Program
• Physiotherapy - Equipment
• Physiotherapy - Pain Management
• Physiotherapy - Other
• Initial Speech Pathology Assessment
• Speech Pathology - Swallowing Assessment
• Speech Pathology - Equipment
• Speech Pathology - Communication
• Speech Pathology - Other
• Other

Funding

Please provide information about how the client's services will be funded.

Funding Body *

• NDIS
• TAC
• Private
• Workcover
• Other

Participant Number *

Email invoices to

Name *

First

Last

Email *

NDIS Plan Dates *

If the client is not an NDIS participant please write N/A.

If you are referring an NDIS participant, please attach current NDIS plan.

Click or drag a file to this area to upload.

Max file size 20Mb.

Allocated NDIS funding to each discipline referred to. Please note we require a minimum of 15 hours allocated to each discipline. *

If the client is not an NDIS participant please write N/A.

Risk

Tell us about any behavioural and other risks, if any, we should know about.

Does the client present with any of the following risks? *

• Behaviors of concern (including verbal and/or physical aggression)
• Forensic history
• History of drug or alcohol abuse
• History of violence
• Mental health concerns
• Weapons or firearms on premises
• No risks

If there are any risks present, please provide further information below. If there are no risks, please write N/A *

Is there any other relevant information you would like to provide?

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Related information

Learn more about our Occupational Therapy, Physiotherapy and Speech Pathology services.

Find out more about us and meet our team.

Contact us to enquire about our services.

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