OT referral Form

Occupational Therapy Referral

Welcome to Hunter Home Modifications occupational therapy referral page. If you have any questions regarding the referral or funding, please contact our department on 4950 4275 option 2. Please fill in the below information to complete a referral to our occupational therapy department. Please note, the information collected is to ensure that we have the relevant details to effectively provide service to you. This information is not disclosed outside of our organisation without your permission.

Referral Date *

Are you the: *

ClientReferrer/Other

Referrer/Other Details

Referrer First name *

Referrer Last Name *

Agency/relation *

Referrer Phone Number *

Referrer Email Address

Is the referrer a client representative, nominee or carer? *

YesNo

Is the client aware of this referral and consents to the referral? *

YesNo

Client Information

Given Name *

Surname *

Date of Birth *

Phone Number *

Email Address

Street Address *

Suburb *

State *

Postcode *

Medical Diagnosis/ Information *

Is the client the main contact? *

YesNo - Alternative contact

Alternative contact person

ReferrerOther

Contact Given Name

Contact Surname

Contact Relation

Contact Phone Number

Contact Email

Funding Details

Funding Agency *

Commonwealth Home Support Program (CHSP)/ My Aged CareNational Disability Insurance Scheme (NDIS)Home Care Package (HCP)Private Referral

Referral Code *During your assessment with My Aged Care, the Regional Assessment Service or Aged Care Assessment Team assessor would have provided you with a referral code number (e.g. 2-123456789) for "Allied Health". Please place this number into the box above. If you are unsure about the referral code please contact our team on 4950 4275 and option 2 for the OT department

NDIS number *

Occupational Therapy Budget *Please enter 0 if unsure. Hunter Home Modifications charges NDIS clients $193.99 per hour. For complex home modifications it may be beneficial to talk to one of our OTs about funding requirements prior to submission of referral on 4950 4275 option 2.

NDIS funding Managment *

AgencyPlan ManagedSelf ManagedUnsure

Plan Manager Details

Please provide LAC or COS contact detailsIf known, please provide contact details including name, phone and email for the client's COS or LAC.

HCP funding available for OT *If the client has complex needs please contact our OT department on 4950 4275 option 2 to discuss funding requirements.

Reason For Referral *

Attachments

Browse

Please attach any recent assessments or information regarding the client that may be useful for service delivery.

Property information

Property Type *

HomeUnit/apartmentDuplexOther

Further Information

Further information regarding the client/referral