Submit an OT Referral

NDIS Referral Form

Let's start with your details.

Enter your full name GenderFemale Male Prefer not to say Non-binary Different Identity (please specify) Date of Birth (DD/MM/YYYY) Address Client Contact Phone Number Client Email Address

Do you/participant identify as Indigenous or Torres Strait Islander descent?AboriginalTorres Straight IslanderAboriginal & Torres Straight IslanderNoneDo not want to answer

Do you/participant have a cultural background or preference you want us to keep in mind?Are there any days that do not suit you for appointments?

Add your representatives details.

Support Coordinator NameSupport Coordinator CompanySupport Coordinator Contact NumberSupport Coordinator EmailRepresentative Contact Name. NOK, POA, EPOA Representative Contact Number Representative Email Address (for signing the Service Agreement)Consent to contact on my behalf? YesNoReason for occupational therapy assessment. This will assist us to match you with the appropriate OT Is this assessment urgent? YesNo

School Visits (Paediatric only)

If you would like your child to be seen at school, has consent been given by the school? YesNo / Not yetSchool Details, including best contact

Add your NDIS Details.

NDIS Number NDIS Approved Disability NDIS Goals NDIS Funding Self ManagedNDIS ManagedPlan Managed

Plan Manager name Plan Manager email (for invoices) NDIS Plan Dates (DD/MM/YYYY-DD/MM/YYYY) and total OT funding amount ($) Has this plan been received on or after 19/05/25? YesNoWith the introduction of funding periods and components in NDIS plans, we now require confirmation of OT Hours avialable for each funding period. This helps us align our services with the plan's structure and ensure continuity of support. Any unused OT hours within a funding period will automatically roll over and to the next funding period to ensure continuation of services.

Breakdown of Funding Periods for OT Services Quarter 1 - funding dates and amount Quarter 2 - funding dates and amount Quarter 3 - funding dates and amount Quarter 4 - funding dates and amount

Please share a copy of the NDIS Plan or a screenshot showing the funding allocated for Occupational Therapy

Upload File

Max file size 10MB.

Uploading...

fileuploaded.jpg

Upload failed. Max size for files is 10 MB.

Referral RequestFCA – 15hrSIL/ILO – 18hrSDA – 25hr Ongoing therapy – 20 hoursMajor Modifications – 25 hoursMinor Modifications or AT – 10 hours Pressure Care Assessment – 10 hours

Safety screening questions

Has a forensic order been issued for this client? YesNoIs there any criminal history or history of violence of anyone who will be on the property? YesNo Are there any illicit substances on the property or in the home? YesNo Anything else we should be aware of?

Add some final details.

Are there any behaviours of concern or a Positive Behaviour Support Plan? If yes – please upload your document.

Upload File

Max file size 10MB.

Uploading...

fileuploaded.jpg

Upload failed. Max size for files is 10 MB.

NDIS Service Agreement

Please review the Service Agreement below before submitting this referral. It confirms the Occupational Therapy services Forbes Care will provide under the participant's NDIS plan, including service fees, billing arrangements, responsibilities, consent and service terms.

Your Occupational Therapy Service
Your selected service and agreed allocation will appear here.

Thank you! Your submission has been received!

Oops! Something went wrong while submitting the form.

Home Care/Support at Home Referral Form

Let's start with your details.

Enter your full name GenderFemale Male Prefer not to say Non-binary Different Identity (please specify) Date of Birth (DD/MM/YYYY) Address Client Contact Phone Number

Do you/participant identify as Indigenous or Torres Strait Islander descent?AboriginalTorres Straight IslanderAboriginal & Torres Straight IslanderNoneDo not want to answer

Do you/participant have a cultural background or preference you want us to keep in mind?Are there any days that do not suit you for appointments?

Next of Kin Details.

Full name Contact Phone Number Relationship (Next of Kin / EPOA / POA / Family Member)

Do you have a representative or other decisions maker involved in your care? (EPOA, GPA , EG)

Package Provider and Funding Information .

Package Level / SAH Classification LevelIs the funding grandfathered home care package? Is there additional Transitioned Funding from unspent Home Care Package or accumulated current Support at Home funding ? Approved AT/HM Funding? Yes
No
Approved AT/HM Funding Level Additional / Alternative Funding: End of life Pathway
Restorative Care Pathway
Care Partner NameCare Partner Contact Details Package/Funding Company Are you self managing your funding? Yes
No

Add some extra details.

Primary Diagnosis or Health Concerns? Reason for occupational therapy assessment. This will assist us to match you with the appropriate OTReferral Type - Intial Option 3 hour Initial is recommended for multiple prescriptions or complex cases
Includes:
Assessment (Direct)
Travel (Direct)
Standard Report including Recommendations (Indirect)
Liaison with Carer/Guardian/Supports/Care Partner (Indirect)
‍
Total Cost: $660 (incl. GST)
________2 hour Initial is recommended for single items or basic prescriptions
Includes:
Assessment (Direct)
Travel (Direct)
Standard Report including Recommendations (Indirect)
Liaison with Carer/Guardian/Supports/Care Partner (Indirect)l
‍
Total Cost: $440 (incl. GST)
________

Please attach the Notice of Decision & support plan from the aged care assessor ?

Upload File

Max file size 10MB.

Uploading...

fileuploaded.jpg

Upload failed. Max size for files is 10 MB.

Thank you! Your submission has been received!

Oops! Something went wrong while submitting the form.

DVA Referral Form

Let's start with your details.

Enter your full name GenderFemale Male Prefer not to say Non-binary Different Identity (please specify) Date of Birth (DD/MM/YYYY)Address Client Contact Phone Number

Do you/participant identify as Indigenous or Torres Strait Islander descent?AboriginalTorres Straight IslanderAboriginal & Torres Straight IslanderNoneDo not want to answer

Do you/participant have a cultural background or preference you want us to keep in mind?Are there any days that do not suit you for appointments?

Next of Kin Details.

Full name Contact Phone Number Relationship (Next of Kin / EPOA / POA / Family Member)

Add your DVA details.

DVA Number DVA Card Status: GoldWhitePlease specify your treatable condition GP Doctors Name GP Clinic Name GP Provider Number If you have a D904 document, please attach below

Upload File

Max file size 10MB.

Uploading...

fileuploaded.jpg

Upload failed. Max size for files is 10 MB.

Thank you! Your submission has been received!

Oops! Something went wrong while submitting the form.

Submit a referral