Occupational Therapy Referral

Funding Body

Home Care Funding
Home Care Package Level 1Home Care Package Level 2Home Care Package Level 3Home Care Package Level 4CHSP/Private Funding

Organisation

Email to send invoices to

Referrer

Referrer Name

Referrer Organisation

Referrer Position

Referrer Contact number

Referrer Email

Client Details

Client Name

Prefers to be called

Client Date of Birth

Client Gender
—Please choose an option—MaleFemaleOther

Client Address - Unit Number

Client Address - Street Number

Client Address - Street Name

Client Address - Suburb

Client Address - State

Client Type of Home
—Please choose an option—Private Owned ResidencePrivate Rental PropertyPublic HousingAged Care Facility

Access to home: (Please provide any instructions we may need regarding access to the client's home)

Client Contact Details

Who should be our primary point of contact to arrange appointments with?
ClientA relative or other representativeCase manager

Name

Relationship to client

Contact number

Client Medical Details

Please provide client’s medical history or upload a copy of medical history document. If client requires an interpreter, please ensure an interpreter is arranged at the time of the appointment.

Upload medical history document:

Only accept PDF, DOC, and DOCX file formats.

Home Risk Assessment

Are there any issues you are aware of that may impact client, carer, or service provider safety?
NoYes

Please provide more details or send related documents, e.g., Home Safety Assessment.

Only accept PDF, DOC, and DOCX file formats.

* 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.

Billing

OT hourly rate: $135 plus GST

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.

3 hours for Initial OT AssessmentAdditional 3 hours for Follow Up Appointment (e.g., equipment trial)

Notes

Cancellation

Cancellations must be made via telephone to our Office during office hours and at least 24 hours prior to the appointment.

• Cancellations received within 24 hours of the appointment will be charged in full.

• Office hours are Mon-Fri 8am-7pm & Sat 8-12pm.