Referral Form New

Client Referral Form

Date of referral *

Is this referral for a client previously seen by Bridge to Best? *

Services engaged previously? *

Occupational TherapyTherapy Assistant

Main service required under this referral? *

Occupational TherapyTherapy Assistant

Do you require a second service? *

YesNo

Additional service required under this referral? *

Occupational TherapyTherapy Assistant

Client Details

First Name *

Last Name *

Date of Birth *

Preferred Name

Phone Number

Email

Address *

Best Client Contact Method *

Phone - VoicePhone - TextEmailNo direct client contact

Is this a self-referral? *

YesNo

Does the client have a representative?

YesNo

Client Representative

First Name *

Last Name *

Relationship to Client *

Phone Number *

Contact Email *

Best Client Representative Contact Method *

Phone - VoicePhone - TextEmailContact client directly in the first instance

Is the client representative and referrer the same person? *

YesNo

Referrer Details

First Name *

Last Name *

Organisation

Referrer's Relationship to Client *

Other Relationship *

Referrer Phone *

Referrer Email *

Referrer Best Contact Method *

Referrer phone - VoiceReferrer phone - TextReferrer emailDo not contact referrer

*Please note you still continue to receive emails regarding this referral.

Referrer Additional Comments

Referrers Details

First Name *

Last Name *

Organisation

Referrer's Relationship to Client *

Other Relationship *

Referrer Phone *

Referrer Email *

Best Referrer Contact Method *

Referrer phone - VoiceReferrer phone - TextReferrer emailDo not contact referrer

*Please note you will receive confirmations via email

Referrer Additional Comments

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

Funding Information

If other please specify *

Do you have an NDIS participant number? *

YesNo

Please provide further information if you do not have an NDIS participant number *

NDIS Participant Number *

Plan Start Date *

Plan End Date *

Plan Manager Company *

Invoicing Email *If NIISQ, TAC or WorkSafe please enter "standard"

Estimated Budget Allocated for Requested Services - $ or hours

Service Agreement Recipient *

Contact for arranging appointments *

If client/client representative consents, please upload a copy of the NDIS Plan

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Risk Assessment

Is the client's address the location for home visits? *

YesNo

Please provide address for home visits *

Is there mobile phone reception at the home visit address? *

YesNoLimitedUnknown

Mobile phone reception additional comments *

Is the home easy to find? *

YesNo

eg. is the house number visible

Finding the home additional comments *

Is there any extra information that will assist our staff accessing the home? *

YesNo

eg. parking, access codes

Please specify any additional access information *

Are there steps leading to the home? *

YesNo

Please specify additional information *

Are there steps into the home? *

YesNo

Please provide additional information on stairs *

Are there any pets in the home or yard? *

YesNoUnknown

Are the pets inside or outside the home? *

InsideOutsideBothUnknown

Are there any safety concerns in relation to these pets? *

YesNo

Pets additional information *

Will anyone else be present during home visits? *

YesNo

Peoples likely present and their relationship to client *

Are there any behavioural, firearm or substance abuse issues with the Client or any peoples present at the home? *

YesNo

Please describe issues to better protect the therapy team *

Does anyone in the home suffer from an infectious/contagious illness? *

YesNo

Infectious/Contagious Illness additional information *

Risk declaration by referrer

I have answered these risk questions honestly and to the best of my ability. If any risks have been identified, I will provide further information to Bridge To Best to ensure an informed decision is made regarding the client's suitability for home therapy *

Occupational Therapy

Diagnosis and medical history *

Description of services required and other relevant history/information *

Please provide any relevant documents or reports

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Therapy Assistant

Diagnosis / medical history / requirements *

Description of services required and other relevant history/information *

Please provide any relevant documents or reports

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Review by Director - Main Service

Main Service

Suitable for main service *

YesNo

If no provide reasoning: *

Any further information

Main service staff name *

Main service staff email *

Ideal time frame for providing services *

Therapist Review - Main Service

Finalisation comments for Director

If you are unable to accept this referral please discuss directly with your manager.

Please check this box to acknoweldge receipt of this referral *

Director Finalisation - Main Service

Next Steps

Admin setup case file in iinsightAdmin send SA - please choose from list

Service Agreement

Ongoing Support hours or dollars for SA

Other hours or dollars for SA

Other Service Agreement Details

Other specific instruction

Review by Director - Second Service

Second Service

Suitable for second services? *

YesNo

If no provide reasoning: *

Any further information

Second service staff name *

Second service staff email *

Ideal time frame for providing services *

Therapist Review - Second Service

Finalisation comments for Director

If you are unable to accept this referral please discuss directly with your manager.

Please check this box to acknoweldge receipt of this referral *

Director Finalisation - Second Service

Next Steps

Admin send SA - please choose from list

Service Agreement

Ongoing Support hours or dollars for SA

Other hours or dollars for SA

Other Service Agreement Details

Other specific instruction

Admin Setup

Steps Taken *

Setup file in iinsight

SA steps *

SA created Funding plan setup in iinsight - using Total Sum - monetary based - naming convention (KM) Therapy type - Last Name, First Name Therapists involved in care are Case Manager in Case>Assigned toRisk category and notes updated in Case > Risk

SA sent

Sent Service Agreement for signing

Send Service Agreement to:

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