Private Referral CLIENT DETAILS Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date of birth MM DD YYYY Disability/Diagnosis * Is this a Medicare Referral Yes No DETAILS OF PERSON COMPLETING FORM Organisation Name Position/Relationship Name First Name Last Name Phone (###) ### #### Email OT SERVICES REQUIRED Reason for Referral Functional Capacity Assessment Assistive Technolgy (Equipment Assessment) Home Modification Assessment Manual Handling Assessment Vehicle Modifications Daily Living Skills/Capacity Building Intervention Mental Health Intervention Other/Not Sure WHO ELSE SHOULD BE RECORDED AS A CONTACT? * No Additional Contacts Next of Kin (NoK) Employer Other Please provide additional information/the reason for this referral to help us to allocate to the appropriate Occupational Therapist. Are there any known safety risks to the Occupational Therapist working with this client or when in their home environment. * Has this referral already been discussed with the Referral Intake Officer? * Yes No COMMUNICATION PREFERENCES Please verify that the details of these individuals have been included as "Additional Contacts" above Who is the primary contact for scheduling appointments * Client Next of Kin (NoK) Employer/Company Other Who should receive copies of the service agreement for signing * Client Next of Kin (NoK) Employer/Company Other Who should receive invoices for this service * Client Next of Kin (NoK) Employer/Company Other CONSENT TO SUBMIT REFERRAL I agree that I have the client or the NoK's consent to share their personal information with Independent OT for the purpose of Occupational Therapy Assessment and/or services. Thank you for submitting your referral. One of our occupational therapists will be in touch shortly.
