REFERRAL FORM

Our current wait time is 1 month following Wizard OT receiving a Signed Service Agreement for any type of services.

Updated 28th October 2024

We provide the following services:

Direct therapy face to face and via telehealth;
Metabolic therapy coaching;
Functional capacity assessment (FCA) or report;
Sensory assessment and related intervention;
Group therapy sessions.

We do not provide the following services:

Specialist disability accommodation (SDA) assessment or report;
Supported independent living (SIL) assessment or report;
Home modifications (Home Mods) assessment or report;
Assistive Technology (AT) assessment or report.

- We can provide Occupational Therapy to Private Clients and NDIS Participants whose NDIS Plans are Plan Managed;

- We can consider referrals within 30 mins travel from Sunshine (VIC 3020) or via Telehealth;

- Wecan provide face to face services when in local proximity for NSW clients;

- Completion of this referral form does not guarantee a referral will be accepted.

Date of referral *

We are interested in *

1:1 OT Sessions1:1 Therapy Assistant SessionsGroup Therapy Sessions

CLIENT DETAILS

First Name *

Last Name *

Date of Birth *

Known As

Phone Number

Email Address

Gender *

MaleFemaleOther

Funding *

PrivateNDIS - Plan Managed only

Address *

Street address *

City *

State *

Postcode *

I acknowledge that the Client's location is within 30 mins travel of Sunshine, VIC 3020
OR understand that sessions will be undertaken over Telehealth only.
We can provide face to face services when in local proximity for NSW clients. *

Appointment Preference *

Face to FaceTelehealth

Client's Suburb *

CLIENT REPRESENTATIVE DETAILS (IF APPLICABLE)

First Name

Last Name

Phone Number

Email

Relationship to Client

REFERRER DETAILS

First Name *

Last Name *

Phone Number *

Email Address *

Company Name

Role

The person being referred has given consent to this referral and consents to these details being kept on a cloud based client management system *

FUNDING DETAILS

Private Invoicing Email Address *

NDIS DETAILS

Plan *

Plan Managed

NDIS Number *

Plan Manager Company Name *

Plan Start Date *

Plan End Date *

Invoicing Email Address *

REASON FOR REFERRAL

Requested hours available for OT *

Requested hours for Group Therapy Sessions *

Funding Category *

CB Daily - Improved Daily LivingCORE - Assistance with Daily Life

Reason for Referral *

Relevant Medical Information *

If the Client consents, please upload a copy of the NDIS Plan if able

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Any other reports or documents that may assist with Services for the Client

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If your referral is accepted:

Who shall we send Service Agreement to? *

Who is the best contact for arranging appointments? *

How would they prefer to be contacted? *

How did you hear about us?

DIRECTOR REVIEW OF REFERRAL

This Client is suitable for services *

YesNo

If no provide reasoning: *

Next Steps for Admin *

Admin add to waitlist in SploseAdmin setup in SploseAdmin send Service AgreementAdmin arrange initial appointment 30 mins with CareGiver and 1 hour appointment for ClientAdmin arrange other appointment schedule

Hours for Service AgreementPlease specify if different from the requested hours as noted by Referrer

Whom to send Service Agreement to:

Any other info for Admin?

Initial Appointment with CareGiver type *

Initial Appointment with Client type *

Other schedule of initial appointment description *

Whom to liaise with for appointments:

Client Email Address

Representative Email Address

Referrer Email Address

Client Phone Number

Representative Phone Number

Referrer Phone Number

ADMIN SETUP

Setup client

Setup

Setup Client in AsanaSetup Client in SploseIn Other Details include Plan dates, NOK/REP, SC with name, phone and emailIn NDIS details - be sure to add NDIS No., Plan dates again & DiagnosisInvoicing - Extra invoice details NDIS No.Set the BillTo as the Plan Manager (or leave blank if private client)In Associated Contacts - add NOK/REP, SC, anyone else involved in care from emails/docs received, and Admin@WizardOT (Choose CC on Invoices for the admin@wot contact)

Case Budget setup in Splose
Title: SURNAME - DD/MM/YY - DD/MM/YY
Type: Hours
Dates: Date of Referral - End of Plan
Alerts: 4 weeks from EOP, 70% funding used, Gavin

Add End of Plan 6 weeks support activity and mark as "Do Not Invoice"

Easy calculator for EoP date

Service Agreement form

Admin send Service Agreement

Send SA to

Add in link for Unsigned SA to Splose Alerts (with a tag), and Asana and create follow up task for each 7 days *

Ensure any documents or email threads/communication are uploaded from admin@ to the Client's Splose file

Appointment steps

Admin arrange initial appointment 30 mins with CareGiver and 1 hour appointment for Client

Admin arrange other appointment schedule

Other instructions

Save and Complete Later