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Referral Form

Thanks for considering Shoalhaven Mental Health OT for your OT assessment.

Sarah’s appointments are generally booked 2-3 months in advance.

This referral form will allow you to book an appointment directly into her calendar.

Please do not book an appointment, if you do not wish to make a referral at this time.

It would be best if the client is with you in person or via phone while you complete the referral, to confirm their availability too.

Please note Sarah cannot offer NDIS assessments for clients on mental health care plans.

Thank you for your understanding

Consultation

Please select a time below from my available slots, before you continue with this form

Please select your care plan *

NDISMental Health Care PlanSelf Funded (Private Patient)

Please Select an OT Package that is relevant to your needs *

Option 1 (Comprehensive Assessment and Report)

I need an OT assessment and report for my upcoming plan review or because this is my first NDIS plan

Functional Capacity Assessment (incl mental health focus, standardised assessments and identifying care and assistive technology needs)	2-4 hours
Care Needs Report (includes costing table)	8 hours (or time taken)
Non-Face to Face contact (emails, phone calls, scoring assessments, arranging AT etc)	7 hours
Provider Travel Time	1 hour (dependent on number of visits and location)
Provide Travel Distance	$150 (dependent on number of visits and location)
Short Notice Cancellations (dependent on number of cancelled appointments)	1 hour
Total = 21 hours x $193.99 (hourly rate) + $150 = $4073.79

Option 2 A (SIL assessment, Care Needs Report and SIL report)

I need an assessment to identify my care needs and documentation to support an application for Supported Independent Living (SIL)

Functional Capacity Assessment with a focus on accommodation options	2-4 hours
Visit to recommended SIL accommodation to view site where appropriate	1 hour
Home and Living Assessment Report	5 hours
Schedule of Supports table	1 hour
Care Needs Report (outline of care needs and how it links to outcomes of functional capacity and includes a costing section)	8 hours (or time taken)
Non-Face to Face contact (emails, phone calls, scoring assessments, arranging AT etc)	7 hours
Provider Travel Time	2 hours (dependent on number of visits and location)
Provide Travel Distance	$200 (dependent on number of visits and location)
Short Notice Cancellations (dependent on number of cancelled appointments)	1 hour
Total: 29 hours x $193.99 (hourly rate) + $200 = $5,825.71

Option 2 B (SIL assessment and report)

I’ve already had a functional capacity assessment with an OT and received a care needs report in the past 3 months. I only need a Supported Independent Living Assessment and report. My support person will provide information regarding the recommended SIL accommodation.

OT Assessment with a focus on accommodation options	2-4 hours
Home and Living Assessment Report	5 hours
Schedule of Supports	1 hour
Non-Face to Face contact (emails, phone calls, scoring assessments, arranging AT etc)	7 hours
Provider Travel Time	2 hour (dependent on number of visits and location)
Provide Travel Distance	$150 (dependent on number of visits and location)
Short Notice Cancellations (dependent on number of cancelled appointments)	1 hour
Total: 20 hours x $193.99 (hourly rate) + $150 = $4,029.80

Option 3 (Therapy)

I’ve had an OT assessment and received a report in the past 3 months. I would like to attend mental health specific occupational therapy to assist me to achieve my goals and improve my quality of life.

Initial Assessment talk through what you require and how the OT can assist	1-2 hours
Therapy Sessions	4-6 hours (dependent on need and goals identified)
Non-Face to Face contact (emails, phone calls, session preparation, arranging AT etc)	5 hours
Provider Travel Time	4-6 hours (dependent on number of visits and location)
Provide Travel Distance	$350 (dependent on number of visits and location)
Short Notice Cancellations (dependent on number of cancelled appointments)	1 hour
Total: 20 X $193.99 (hourly rate) + $350 = $4,229.80

Option 4 (Assistive Technology)

I need gadgets or equipment (Assistive Technology - AT) to make my life easier considering my disability. (I do not require complex AT e.g. power wheelchairs)

Functional Capacity Assessment	2-4 hours
AT trial (e.g. recliner lift chair trial or electric height adjustable bed trial)	1-2 hours dependent on AT required
AT Report	4-8 hours per device (e.g. 4 hours recliner and 4 hours bed)
Home visit(s) follow up once AT is delivered to provide training	1-2 hours
Non-Face to Face contact (emails, phone calls, arranging AT etc)	5 hours
Provider Travel Time	2-3 hours (dependent on number of visits and location)
Provide Travel Distance	$200 (dependent on number of visits and location)
Short Notice Cancellations (dependent on number of cancelled appointments)	1 hour
Total: 22 x $193.99 + $200 = $4,467.78

Option 5 (OT Assessment for younger individuals (below age 18) and care needs report)

This is an estimate only and will differ dependent on needs of the participant during assessment process

Functional Capacity Assessment (involves work with caregivers and includes standardised paediatric assessments, school visit if relevent. These assessments are lengthy and need to be split to suit the young person’s psychological tolerance and cognitive abilities)	6-8 hours
NDIS Requested Reports - Care Needs Report	10 hours (or time taken)
Non-Face to Face contact (emails, phone calls, scoring assessments, arranging AT etc)	7 hours
Provider Travel Time	2-3 hours (dependent on number of visits and location)
Provide Travel Distance	$360 (dependent on number of visits and location)
Short Notice Cancellations (dependent on number of cancelled appointments)	1 hour
Total: 29 hours x $193.99 (hourly rate) + $360 (travel distance ) = $5,985.71

Option 6 (Sensory Assessment and Report)

Sensory Assessment	2 hours
Sensory Report	4 hours
Home visit to deliver and demonstrate use of sensory AT	1-2 hours
Non-Face to Face contact (emails, phone calls, scoring assessments, arranging sensory AT etc)	4 hours
Provider Travel Time	1-2 hours (dependent on number of visits and location)
Provide Travel Distance	$150 (dependent on number of visits and location)
Short Notice Cancellations (dependent on number of cancelled appointments)	1 hour
Total: 15 x $193.99 + $150 = $3,059.85

Please Indidicate if you have enough funds/hours for the above selected *

YesNo

Please indicate how many hours/funds you have available *

In your own words, the reason for your referral *

Referrer Details

NDIS Participant Referral form

Please note only referrals for NDIS participants who have a plan manager or the NDIS plan is self-managed (not agency managed) will be accepted.

How your NDIS plan is managed? *

Self- Managed (managed by NDIS participant, family or other nominated person)Plan Managed (managed by a plan manager)Agency Managed (managed by the NDIA)

Please note I only accept referrals for NDIS participants who have a plan manager or the NDIS plan is self-managed (not managed by the NDIA).

Unfortunately, I cannot accept your referral at this time.

You are welcome to consult the NDIS portal to search for other providers who offer services for clients with Agency managed plans. Provider finder | NDIS

Referrer Details (Person Making the Referral)

I have obtained consent from the participant to make this referral and provide Shoalhaven Mental Health Occupational Therapy with the participant's personal and medical details. *

First Name *

Last Name *

Organisation *

Referrer Role *

Email Address *

Phone Number *

Reason For Referral

Diagnosis *Please list ALL mental health and physical conditions

Please upload additional medical information

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Participant Details

First Name *

Last Name Participant *

Date of Birth

Phone Number *

Email Address *

Participant Address *

Street address *

City *

State *

Postcode *

Participant Accommodation

This information is required as functional assessments are completed within the participants home.

Please Select Accommodation Type *

Lives AloneLives with a carer / familyLives in residential aged care facility (please provide details below)Lives in a group home / SDA facility (please provide details below)In HospitalShort term accomodation (please provide details below)

Accommodation details

Participants Next of Kin

Please provide a name and contact number for the participant's NOK or Support Person to arrange appointments with: *

Is this the participant’s NDIS plan nominee or person responsible? *

YesNo

Does this person live with the participant? *

YesNo

Is this person aware of this referral? (If not, please remember to inform them) *

YesNo

Does the participant have a plan nominee? *

YesNo

Is this person the parent/guardian? *

YesNo

Does the participant have a Legal Guardian? (If yes please provide details below) *

YesNo

Legal Guardian Full Name

Legal Guardian Phone

Legal Guardian Email

NDIS Details

Plan Manager

Organisation *

Plan Manager Full Name

Phone Number *

Email *

NDIS Details

NDIS Number *

Plan Start Date *

Plan End Date *

Please attach NDIS Plan / Request for service *

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Mental Health Care plan / Self Funded Referral Form 1

I understand that I will need to pay for this service upfront *

I understand, the Occupational Therapist cannot perform NDIS assessments under a Mental Health Care Plan. *

Client First Name *

Client Last Name *

Client Phone *

Client Email *

Client Date of Birth *

Client Address *

Street address *

City *

State *

Postcode *

Preferred Method of Contact *

PhoneTextEmailMail

Medicare Details

Medicare First Name *

Medicare Last Name *

Medicare Number *

Individual Reference Number *

Expiry Date *

Diagnosis *Please list ALL mental health and physical conditions

Attachments

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mental health care plan, referral letter, discharge summaries, specialist reports, school counsellor reports

Emergency Contact / Support Person

Emergency Contact Full Name *

Emergency Contact Phone *

Emergency Contact Email *

Will this person be attending your first appointment with you? *

YesNo

Do you consent to the Occupational Therapist contacting this person during an emergency or for further information? *

YesNo

GP Details

Medical Practice *

Name of GP

Practice Email *

Practice Phone *

MH - Reason for Referral

Reason for referral *

Mental health OT assessmentI have a mental health care planI would like specific assistance (please select below)

My readiness for therapy

Yes I definitely want to attend and do the workSomeone else has asked me to attendI’m not really sure but open to giving it a goOther

Payment Information *

Mental Health Care PlanSelf-Funded

Consultation

I have selected a consultation time and have filled in the form. I understand that I need to click submit on the form, not just the consultation for it to be recognised as submitted *

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