Wellnest Health

Funding Body *

Home Care Package (HCP)

Commonwealth Home Support Programme (CHSP)

Private Funding

Referrer name *

First Name

Last Name

Who should be our primary point of contact to arrange appointments with? *

First Name

Last Name

Contact number *

(###)

###

####

Client details *

First Name

Last Name

Clients date of birth *

MM

DD

YYYY

Client preferred contact method and information

Client

A Relative

Case Manager

Preferred client contact information

First Name

Last Name

Primary phone number

(###)

###

####

Are there any issues around safety that our therapists need to be aware of? *

Yes

No

If the client requires an interpreter, please ensure an interpreter is arranged at time of appointment *

I understand

Consent *

By ticking this box, you confirm that you have obtained consent from the client/guardian to refer and provide personal health information to Wellnest Health

I confirm that I have obtained consent from the client/guardian

Billing *

By ticking the box, you confirm that you approve the following hours for OT services. The time billed includes 30 minutes travel, appointment, documentation, and case work. There may be times when the clinician does not require all approved hours. If additional hours are required, the clinician will contact you to obtain approval before proceeding. OT hourly rate: $135 plus GST

I confirm agreement of 3 hours for Initial OT Assessment

Cancellation Policy *

Cancellations must be made via telephone (8842 3668) to our office during office hours and at least 24 hours prior to the appointment. Office hours: Mon - Fri 8am - 7pm & Sat 8am - 12pm. * Cancellations received within 24 hours of the appointment will be charged in full

I agree with the above Cancellation Policy