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.

You may be interested in viewing our referral information, current availability, service areas, and information on NDIS or privately funded clients depending on funding circumstances.

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

Please complete the form below and note compulsory fields are marked with a red asterisk.

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Client Details

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

Client Name *

First

Last

Client Date Of Birth *

Client Address *

Address Line 1

City

State / Province / Region

Postal Code

Client Phone Number *

Client Email *

Client Accommodation Type *Select accommodation typePrivate homeSupported Disability Accommodation (SDA)Medium Term Accommodation (MTA)Aged CareOther

Next of Kin / Alternative Contact

Next of Kin / Alternative Contact Name

First

Last

Next of Kin / Alternative Contact Phone Number

Next of Kin / Alternative Contact Email

Next of Kin / Alternative Contact Relationship to ClientSelect relationship to clientParentChildSiblingSpouseGuardianOther

Referrer Details

Who should we contact regarding this referral?

Referrer Name *

First

Last

Referrer Phone Number *

Referrer Email *

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

Referral Information

Please provide details about the services you require.

Which services are you referring for? *

• Occupational Therapy
• Physiotherapy
• Speech Pathology

Diagnosis/Conditions *

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.

Please select the services you require.

Occupational Therapy *

• 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

Physiotherapy *

• Initial Physiotherapy Assessment
• Physiotherapy - Home Exercise Program
• Physiotherapy - Equipment
• Physiotherapy - Pain Management
• Physiotherapy - Other

Speech Pathology *

• Initial Speech Pathology Assessment
• Speech Pathology - Swallowing Assessment
• Speech Pathology - Equipment
• Speech Pathology - Communication
• Speech Pathology - Other

Funding

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

Funding Body *

• NDIS
• TAC
• Private
• Workcover
• Other

Participant Number *

Claim Number *

Who should we email invoices to?

Name *

First

Last

Email *

What are the participant's NDIS Plan Dates *

Please attach the participant's current NDIS plan.

Click or drag a file to this area to upload.

Max file size 20Mb.

List the participant's NDIS funding allocated for each service referred to. Please note we require a minimum of 15 hours allocated to each discipline. *

List the client's TAC funding allocated for each service referred to. Please note we require a minimum of 10 hours therapy and 4 hours travel allocated to each discipline. *

Risk

Are there any behavioural or other risks we should know about? *

• Yes
• No
• Not sure

Which of the following risk are present? *

• 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
• Other

Please provide further information about the risks below. *

Other Information

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

Please add any files related to your referral such as discharge summary, medical or specialist reports, behaviour plans etc

Click or drag files to this area to upload. You can upload up to 5 files.

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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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