Referrals

TERRITORY THERAPY SOLUTIONS - REFERRAL FORM

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CLIENT DETAILS

Client's First Name *

Client's Last Name *

Client's phone

Client's Mobile

Date of Birth. (Note: we do not accept referrals for children) *

Client's Email

Preferred Communication Method

CLIENT ADDRESS

Street Name (include number) *

Suburb *

State *

Region *

NDIS Location Classification

DEMOGRAPHICS

Indigenous Status *

Gender *

Interpreter Required *

Interpreter Details (Language and dialect)

Country of Birth *

Language spoken at home *

Is the client under legal guardianship *

Who do we contact for appointments if not the client?

Alternative Contact First Name

Alternative Contact Phone

Alternative Contact Last Name

Alternative Contact Email

Relationship to Client

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MEDICAL DETAILS

Primary diagnosis (refer to our referral criteria for accepted diagnosis) *

Medical History *

Assessments in the last two years

If yes

If Yes, please attach and send your files below

File Upload 1 (please ensure it is under 5MB)

pdf, doc, docx, jpg files only please. If you have other file types please label them clearly and send them to referrals@territorytherapysolutions.com.au

Functional Status *

Mobility Status *

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RISKS AND ACCESS

All Clients

Remote and Very Remote Clients

Violence or Aggression risks at the premises? *

Animal related risks at the premises? *

Does the premises have reliable mobile phone coverage? *

Is a 4WD required to access the client's property? *

Does access get affected due to bad weather? *

Additional Risk information?

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NDIS FUNDING PLAN AND DETAILS

NDIS Number

Fund Management

Plan Manager First Name

Plan Manager Last Name

Plan Manager Email

PLAN Start Date

PLAN End Date

Plan Manager Company

Plan Manager Invoice email

Plan Manager Phone

Please upload a copy of the participant's current plan

Please provide a copy of participant's NDIS goals

File Upload 2 (please ensure it is under 5MB)

pdf, doc, docx, jpg files only please. If you have other file types please label them clearly and send them to referrals@territorytherapysolutions.com.au

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OTHER FUNDING DETAILS

(1) Claim Number

(2) Private Health Fund Member Number

Private Health Fund Name

(3) Medicare Number

Medicare Expiry Date

*** if not claiming via the above sources, please leave blank.

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REFERRER INFORMATION - This includes CoS, Insurance Company, Guardian or third party.

Referrer First Name

Referrer Last Name

Referrer Company

Referrer Phone

Referrer Email

Referrer Postal Address

Referrer Relationship

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ADDITIONAL CONTACTS

Contact 2 First Name

Contact 2 Last Name

Contact 3 First Name

Contact 3 Last Name

Contact 2 Company

Contact 2 Phone

10 of 10 Character(s) left

Contact 3 Company

Contact 3 Phone

10 of 10 Character(s) left

Contact 2 Email

Contact 3 Email

Contact 2 Postal Address

Contact 3 Postal Address

Contact 2 Relationship

Contact 3 Relationship

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Click the tab at the top of this form for a glossary of terms.

Click the tab at the very top of this form for a glossary of terms.

SERVICES

OCCUPATIONAL THERAPY

Occupational Therapy Services - Available (expand on reason in Additional Info)

OT Assessment & Review
SIL Assessment & Review
SDA Assessment & Review
Sensory Assessment & Review
Home Modification Assessment
Assistive Technology Assessment (list equipment under Additional Info for OT Service Request)
Upper Limb Assessment & Intervention
Training Support Workers e.g. Home Programs (list who under Additional OT Service Request i.e, Carers, Support Workers)
Program Development (list if sensory or ADL, under Additional Info for OT Service Request)

OT NDIS Category / Service Code

OT Amount Allocated (NDIS only)

Additional Info for OT Service Request

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DRIVING ASSESSMENT

Driving Assessment Services - currently not accepting referrals

Return to Driving Injury or Illness
Vehicle Modification

Driving Assessment NDIS Category / Service Code

Driving Amount Allocated (NDIS only)

Please tick if applicable.

Have a current drivers license?

Obtained Medical clearance from GP

Is the license under suspension?

Vehicle Modifications

If you ticked the obtained medical clearance (form L2) above. Please attach a copy here from your GP. (pdf, doc, docx only please)

File Upload 3 (please ensure it is under 5MB)

Additional Info for Driving Assessment (Any modifications?)

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PHYSIOTHERAPY

Physiotherapy Services Available

Physio Assessment & Review (includes hydrotherapy, equipment sourcing and program development)

Physiotherapy NDIS Category / Service Code

Physiotherapy Amount Allocated (NDIS only)

Additional Info for Physio Services

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SPEECH PATHOLOGY

Speech Pathology Services Available

Communication Assessment
Meal-Time Management Plan
Swallowing / Dysphagia Assessment
Stuttering Treatment
Communication Therapy
AAC (Alternative and Augmentative Communication) Assessment and Training
Support Worker Training

Speech NDIS Category / Service Code

Speech Amount Allocated (NDIS only)

Additional Info for Speech Services

OTHER DETAILS

How did you hear about us? *

Other way you heard about us

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Please note by submitting this referral form you and/or the client understand that:

These records are owned by this organisation.
Information within these records will be shared with other staff within the organisation, on and only when staff require the information to carry out their duties.
You or the client can ask to see records and receive a copy.
Records are archived for a set period according to policy and procedure.
That all information obtained will be kept confidential.

Thank you for completing our referral form please push the submit button and you should receive confirmation of your submission within an hour. If you are not finished please hit save and you can come back later to complete your form.

If you need to contact us further please see our details below.

Office 201, Ground Floor, Building 2, Darwin Corporate Park, Berrimah NT 0828 PO Box 469, Berrimah NT 0828 P: 08 8927 0469 | F: 08 8927 0819 referrals@territorytherapysolutions.com.au

Referrals

TTS REFERRAL FORM

TERRITORY THERAPY SOLUTIONS - REFERRAL FORM

CLIENT DETAILS

CLIENT ADDRESS

DEMOGRAPHICS

Who do we contact for appointments if not the client?

MEDICAL DETAILS

If Yes, please attach and send your files below

RISKS AND ACCESS

All Clients

Remote and Very Remote Clients

NDIS FUNDING PLAN AND DETAILS

Please provide a copy of participant's NDIS goals

OTHER FUNDING DETAILS

*** if not claiming via the above sources, please leave blank.

REFERRER INFORMATION - This includes CoS, Insurance Company, Guardian or third party.

ADDITIONAL CONTACTS

SERVICES

OCCUPATIONAL THERAPY

DRIVING ASSESSMENT

Please tick if applicable.

PHYSIOTHERAPY

SPEECH PATHOLOGY

OTHER DETAILS