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Home
Who We Are
Our Story
Our Approach
Our Clinicians
Our Management and Admin Team
Our Locations
Cultural and Community Mentoring Group
Careers and Pathways
First Nations Careers
What We Do
Psychology and Counselling Services
NDIS Services
Carer and Support Person Services
Commonwealth Psychosocial Support Program (CPSP)
Low Intensity Psychological Therapy (LIPT)
Professional Development
Staff Organisation Wellness and Enhancement Services
News and resources
News
Videos
Useful links
Events
Referral Forms
Contact
NDIS Psychology & Occupational Therapy Referral
Fill in and submit the form below, or
Download a blank copy
Step
1
of
3
33%
DETAILS OF REFERRAL
Referral Date
(Required)
Day
Month
Year
Plan Management Type:
NDIA Managed
Plan Managed
Self Managed
Consent for referral
(Required)
Client consent
Guardian/Child Representative/Nominee (if aged under 18 or has an appointed Guardian/Nominee)
This field is hidden when viewing the form
Referral Type
Select referral type
Workcover
Employee Assistance Program (EAP)
Other
This field is hidden when viewing the form
Service Location
Select location
Rockhampton
Thursday Island
Nambour
Other
This field is hidden when viewing the form
Other Referral Type
This field is hidden when viewing the form
Other Service Location
REFERRER
Name of referrer
(Required)
Organisation
(Required)
Referrer position/profession
(Required)
Provider number (if applicable)
Referrer phone number
(Required)
Referrer email
(Required)
Referrer address
(Required)
CONSUMER DETAILS
Name
(Required)
Preferred Name
D.O.B.
(Required)
Day
Month
Year
Gender
(Required)
Select
Female
Male
Prefer not to disclose
Cultural heritage
(Required)
Aboriginal
Torres Strait Islander
Both
Neither
Culturally & Linguistically Diverse Background
Primary Disability
Secondary/Additional Disability/Disabilities
Address
Experiencing homelessness
Yes
Email
Phone numbers
GUARDIAN / CHILD REPRESENTATIVE / NOMINEE DETAILS
(If aged under 18 or has an appointed guardian/Nominee)
Name
Contact number
Relationship
PERSON TO CONTACT FOR MAKING APPOINTMENT/S
Name
Contact number
Relationship
NDIS PLAN DETAILS
NDIS ID Number
(Required)
NDIS Plan Ends
(Required)
NDIS Plan Attached
(Required)
Yes
No
Available Funding Amount for Requested Supports
Please tick at least one of the following therapies
(Required)
Psychology Therapy
Occupational Therapy
Occupational Therapy FCA
Frequency of appointments required
(Required)
Monthly
Fortnightly
Preferred Appointment Day
Day
Month
Year
Preferred Appointment Time
Hours
:
Minutes
AM
PM
AM/PM
Preferred session location
(Required)
WWH Clinic
Consumers Home
Other
Specify other preferred session location
NDIS Plan Goals
(Required)
ADDITIONAL INFORMATION
Reason for referral
(Required)
Are there any relevant assessments (e.g. OT FCA, Progress Reports)
(Required)
Are there any risk factors we should be aware of?
(Required)
Yes
No
Please specify risk factors
Is the person at increased risk of suicide. eg. Thoughts, Plan or intent
(Required)
Yes
No
Please specify increased risk
Other services consumer is accessing
Example: Are you currently accessing OT or psychology, or have you been trying to access OT or psychology for a period of time? If yes, please provide details of how long you have been receiving or waiting for services.
HOME VISIT RISK ASSESSMENT
If any risks are identified, further assessment will be conducted prior to the home visit.
Does the consumer live alone?
(Required)
Yes
No
Are there any aggressive animals?
(Required)
Yes
No
Does anyone at home have a history of violence?
(Required)
Yes
No
Is there any clutter or tripping hazards?
(Required)
Yes
No
Does anyone at home have any substance abuse?
(Required)
Yes
No
Are there firearms in the home?
(Required)
Yes
No
Does anyone at home have an infectious disease?
(Required)
Yes
No
Is there mobile phone service at the home?
(Required)
Yes
No
Will there be anyone else present at the home at the time of the session? (If yes, please provide details)
(Required)
Yes
No
Who will be present at time of appointment?
(Required)
Are there any other risks that affect the clinician safety and wellbeing by accessing the property?
(Required)
Yes
No
Other potential risks to clinician safety and wellbeing
(Required)
Is there a space for the clinician and consumer to meet privately?
(Required)
Yes
No
Other Relevant information
Falls risks
(Required)
Yes
No
Carer fatigue/stress
(Required)
Yes
No
Mobility
(Required)
Yes
No
Other
(Required)
Yes
No
Specify details for other relevant information
CONSUMER PREFERENCES
Preferred gender of worker
(Required)
Female
Male
No preference
Preferred contact method
(Required)
Mobile
Home phone
Email
via Referrer
Home visit
Other
Other Preferred contact method/s
(Required)
Is it OK to leave voicemail/send SMS?
(Required)
Voicemail
SMS
Either
*Is it okay to leave a letter/card at home?
(Required)
Yes
No
Other preferences
SUPPORT COORDINATOR DETAILS
Name
Organisation
Phone
Email
PLAN MANAGER DETAILS
Name
Organisation
Phone
Email
HOW DID YOU HEAR ABOUT US?
How did you hear about us?
(Required)
Social Media
Website
NDIS provider finder tool
Word of mouth
Have worked with us previously
Other
Other ways you heard about us
SUPPORTING DOCUMENTS
Upload relevant reports and documents (ie. Risk Assessment)
Drop files here or
Select files
Accepted file types: jpg, pdf, docx, Max. file size: 50 MB.
For more information or assisstance:
Freecall:
1800 732 850
(Choose 4 for NDIS)
Email:
ndis@wakai-waian.com.au
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