MOTORS

REFERRAL

a group of smiling professionals collaborating at a conference table

We welcome your referral

If you are keen to work with us, then please complete the referral form. It is crucial that it is completed accurately and in full to minimise the chances of a delay in us being able to review and allocate you or your participant to the most suitable therapist.

Please don’t fear rejection or judgement based on past or current risky behaviours – we are comfortable working with risk – we just need to know about it.

Step 1 of 12 - Client Details

Client Name(Required)

First Last

Client Address(Required)

Client DOB(Required)

Client Phone(Required)

Client Preferred Pronouns(Required)

Client Email

Client Preferred Language(Required)

Client NDIS Plan Number*(Required)

Start Date(Required)

End Date(Required)

Living arrangements:*

Living arrangements(Required)

Alone

Partner/ family Supported Accommodation

Other

Living arrangements - other details(Required)

Describe(Required)

Who is the primary contact? (NOK/Carer/Guardian)*

Contact Name(Required)

Contact Phone(Required)

Contact Relationship(Required)

Are you referring yourself*

Referrer Self referring?(Required)

Yes

Other

Self Referring - other details(Required)

Referrer Name(Required)

Referrer Organisation(Required)

Referrer Address(Required)

Referrer Phone(Required)

Referrer Email(Required)

Role*

Referrer role(Required)

Plan Manager

Treating Clinician

Family member

Supporting Coordinator

Other

Referrer role - other details(Required)

Diagnosis(Required)

Do you/the client have any supports/services in place?*

Support Services(Required)

GP contact details

GP Name

GP Phone

GP Address

GP Email

reason for referral(Required)

Functional (ADL) Assessment

Mental Health support

Home Assessment

OT Intervention services

Home Modifications

Second Opinion

Secondary Consult

Other...

reason for referral - other details(Required)

What would you/ your client like to achieve from this referral? *

referral desired outcomes(Required)

SAFETY & Risk ISSUES (for the safety of our staff, it is mandatory this section is completed in full. Any “Y” please provide further information ) *

Is anyone at your / the client’s property, known to be aggressive or violent*

violence & agression?(Required)

Yes

violence - other details(Required)

Does anyone at your/the clients property have a criminal history?*

criminal history?(Required)

Yes

criminal history - other details(Required)

Does the client have a behavioural support plan in place?*

behavioural support?

Yes

behavioural support - other details(Required)

Is there a history of drugs or alcohol misuse at the property?*

drugs and alcohol?(Required)

Yes

drugs & alcohol - other details(Required)

Are you aware of any occupant having an infectious disease? (i.e. chicken pox / shingles / gastro, etc.)*

infectious disease?(Required)

Yes

infectious disease - other details(Required)

Are there any other factors we should be aware of? If YES, please describe:*

pets?(Required)

Yes

pets - other details(Required)

Does the client/you have any pets at your premises?*

other factors?(Required)

Yes

Other factors - details(Required)

What type of OT report is required?*

OT Type(Required)

Short

Detailed

How many hours of service are you authorising for OT to complete the assessment (including travel, *** please note average functional assessment is between 8-12 hours including report writing, an average SIL/ILO assessment is a minimum of 20 hours)*

Auth. Hours(Required)

hours @ $193.99

Auth. Travel costs(Required)

travel non labour costs @ $1 per km * Total Cost

Auth. toll costs

travel non labour costs: road tolls

Auth. Total Cost(Required)

TOTAL COST

Consent(Required)

I authorise for MOTORS to claim payment(Required)

I authorise for MOTORS to claim payment for the costs as outlined in this form entry

Who is responsible for paying the account? *

Responsible payer(Required)

Private organisation

Self

Other

Payer name

Responsible account holder(Required)

Account holder phone(Required)

Account holder Email(Required)

Alt. contact person(Required)

Alt. contact phone(Required)

Alt. contact Email(Required)

NDIS Code(Required)

Additional information

Drag & Drop or Upload collateral documentation

File

Drop files here or

Accepted file types: pdf, doc, docx, zip, Max. file size: 4 MB, Max. files: 4.

Risk assessment completed with Client/Carer

Risk Assessment completed(Required)

Yes

Client/Carer has consented to home visit

Client/Carer has consent(Required)

Yes

Client has consented to return to hospital (if inpatient

Return to hospital consent(Required)

Yes

Type of residence:

Type of residence:(Required)

House

Unit

OOH

Aged Care Facility

Caravan Park

Other...

Type of residence - other details(Required)

Are street signs or property number hidden from view?

Are street signs hidden?(Required)

Yes

Is the house hidden from the street?

Is house hidden?(Required)

Yes

Is parking on the street / driveway difficult?

Is parking difficult?(Required)

Yes

Is the gate difficult to open?

Is gate difficult(Required)

Yes

Are there uneven / dangerous paths leading to the house?

Are paths dangerous/uneven?(Required)

Yes

Are there any dangerous or slippery steps?

Are steps dangerous/slippery?(Required)

Yes

Does the client / carer have difficulty opening the door?

Does client have difficulty opening door?(Required)

Yes

Does the client need to have another person present?

Does client need another person present?(Required)

Yes

Does the client have any religious or cultural considerations? E.g. Female/Male clinician preferred

Does the client have any religious or cultural considerations?(Required)

Yes

Any animals with open access to the front of the property or inside the house?

Are there pets with access to the property?(Required)

Yes

Is it likely that any people in the house/home will be smoking or drinking alcohol during our visit?

Will anyone be smoking or drinking during visit?(Required)

Yes

Is there known substance use / abuse amongst people who may be present?

Is there known substance use amongst people who may be present(Required)

Yes

Does the client or other people in the home have a history of actual or threatened violent or aggressive behaviours? e.g. Code grey whilst an inpatient? Forensic/Offending Hx?

Does the client or other people in the home have a history of actual or threatened violent or aggressive behaviours?(Required)

Yes

Are there any known weapons or guns in the house?

Are there any known weapons or guns in the house?(Required)

Yes

Are they locked away?

Are they locked away?(Required)

Yes

Remote area? (>30 minutes from staff base?)

Remote area?(Required)

Yes

Is there difficulty with mobile phones and/or working landline?

Is there difficulty with mobile phones and/or working landline?(Required)

Yes

Any additional hazards identified? E.g. seasonal bushfire risks?

Any additional hazards identified?(Required)

Yes

Person completing this form: Please insert your name below as your electronic signature to authorise for OT services to commence based on the information provided in this form:

Referrers Name(Required)

First Last

Signing Date(Required)

DD slash MM slash YYYY

Please note that the information provided above will form the contractual service agreement between MOTORS and the client/participant or their authorised representative.

Please contact admin@motors-ot.com.au for any further questions.

We look forward to working with you.

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