Client intake form

Allied Health service client referral form

Date referral received

Client Details

Client First Name *

Client Last Name *

Date of birth *

Address (client home) *Include any specifics re parking or access

Email address (client or representative) *

Phone number

Is client their own decision maker? *

YesNo

If No (above), name and contact details of decision maker

Emergency contact person

Emergency contact person phone/email

Referrer

Name *

Phone number *

Role (e.g. support coordinator, family member) *

Referrer email address *

Referral Information

Reason for referral (tick all that apply) *

Functional Capacity Assessment and Report (FCA)Supported Independent Living Assessment and Report (SIL)Specialist Disability Accommodation Assessment and Report (SDA)Assistive Technology (complex)Assistive Technology (low-risk)Minor Home ModificationsOngoing InterventionOther

If Other, please add detail below:

Client conditions/impairments. *If NDIS client, please specify NDIS accepted condition/s.

Behaviours of note - tick all that apply *

No behavioural concernsAnxietyMood changesThreatening behavior

NDIS goals

Please indicate which reports you will provide for collateral

Previous/current allied health report/s (OT, Physiotherapy, Speech Therapist etc.)Previous/current Positive Behaviour Support PlanGP and/or Medical Specialist report/letterDischarge summary/iesFamily statementOther

If Other, please note below

Upload reports here

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Financial Information

Reference number e.g. Participant number, member number *

If private health fund, please specify fund name below

Preferred Item Code for Allied Health Service

Plan end date (NDIS) or Package end date (HCP) *

Funding approval source if NDIS client

Plan ManagerNDIA managedSelf-managed

Email address for payer

Name (Plan managed or Self managed)

Phone contact

Please send Service Agreement documents as a *

Link which can be completed and signed onlinePDF for printing, signing, scanning and returning by email

Privacy Policy Agreement

Privacy Policy - Platinum Allied Health Australia *

Demographic information

Language/s spoken if English is a second language:

If Other, please specify below

Signature

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