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Home » Admin Referral and Pre Visit Form

Admin Referral and Pre Visit Form

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Referral Form and Pre Visit

Please complete the following referral form, you can leave additional comments and attach file/images as well.

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Referral Details

Is this referral being accepted over a phone call with a Community Therapy team member?*

Yes

Call recording consent*

Yes

Before we start, I need to advise you that our calls are recorded for quality assurance purposes. Are you okay with that?

Community Therapy Team Member Name*

Person Spoken With To Complete Referral*

Name of person completing form

Referrals required

Dietitian

Exercise Physiology

Occupational Therapist

Massage Therapy

Physiotherapist

Speech Pathology

Client First Name

Client Last Name

Date of Birth

Client Address

Client Email Address

Client Phone Number

Additional Client Phone Number

Referred By

Referrer's Phone Number

Referrer's Email

Client Funding Type

Who is your private health insurer?

DVA Accepted Disability - Please enter the exact wording of the accepted disability

DVA - Is the veteran living in a residential aged care facility?

Yes

DVA & RACF

Admin to phone RACF to confirm resident not recieving OR able to access service from them

Admin to phone DVA to confirm eligible for our service

Funding type if not listed

NDIS number

NDIS plan dates

How is the NDIS plan managed?

Dietitian service - if agency managing your plan where would you like Dietetics invoiced to?

Email address for sending invoices to if NDIS plan is self or plan managed

Email address for invoices to be sent to

Reason for Referral

Medical Conditions

Primary Disability(s) for the NDIS

Other Medical Conditions

Pre Visit Safety and Preferences

Do you have a preference of male or female clinician?

No preference

Male

Female

Would you like someone present with you at the appointment such as a family member or carer?

Do you have any religious or cultural preferences, including indigenous or torres straight islander background, that you would like us to respect?

Do you have any communications preferences, such as language needs or preferring communication via phone, email or text message?

Mobile phone reception at your property?

Yes

Other

Any parking considerations at your property?

Any pets and if so safety concerns?

Does anyone at the house smoke

Yes and they can refrain from smoking whilst we are present

Other

Does anyone at the property have a criminal record or is there a history of dangerous objects, such as weapons, or violence at the property?

Yes

Other

Do you or any household member live with an infectious disease?

Yes

Other

If yes, Admin to advise leadership@communitytherapy.com.au to ensure appropriate PPE and Waste Disposal options are in place at household.

Completed

Do you or a household member receive active treatment for cancer requiring chemotherapy or cytoxic drugs? (If yes please advise leadership@communitytherapy.com.au)

Yes

Other

Do you or any household member use needles in the house (such as for Diabetes)? If no, are they safely handled and disposed of in a sharps bin in the house. (If yes please advise leadership@communitytherapy.com.au)

Yes

Other

Massage Therapy only - Client advised - Please ensure you have a clear space for our Massage Therapist to place their table and also have 1-2 towels available. Please advise Central Coast private fee paying clients are unable to access private health rebates.

Yes

We advise all of our clients about our cancellation policy. We have a full fee cancellation policy if we receive a cancellation with less than 1 business days notice prior to your appointment.

Acknowledged

Other

We advise all of our clients about our cancellation policy. We have a full fee cancellation policy if we receive a cancellation with less than 2 business days notice prior to your appointment.

Acknowledged

Other

Client acknowledges that it is very helpful to have supporting documents such as medical documents and also a list of current medications at the visit. Please advise them of the current wait time. They can call the office on 1300 031 935 with any questions.

Yes

Additional Information

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Community Therapy's mission is to support, enable and empower our clients to live enriched and meaningful lives. Our Allied Health Professionals really do love their work and we believe it shows in the quality of service we provide. We partner with aged care providers, NDIS participants and organisations, private health insurers and healthcare companies to make people’s lives better.

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Our Core Services

Physiotherapy
Occupational Therapy
Dietetics
Speech Pathology
Massage Therapy
Allied Health Assistants

Models of Care

NDIS
Aged Care
Hospital at Home
Paediatrics
Excercise groups