Home Care Packages / Other Referral - Holistic Occupational Therapy

Other Referrals

Please fill out the appropriate boxes below and our Occupational Therapy team will get back to you.

"*" indicates required fields

Referrer Full Name:*

Referrer Email:

Referrer Phone Number:*

Client Name*

First Last

Date of Birth*

Address*

Street Address Address Line 2 City State ZIP / Postal Code Country

Best Contact Person:*

Please advise who the best person is to contact regarding this referral/booking appointments. Please also provide relevant contact details (including phone number):

Client Email (if applicable)

Medical condition*

Please comment on the client's current medical condition if known (e.g., medical diagnosis, recent hospital admission, recent surgery etc.)

Reason for referral*

Is an OT Report required?*

Sometimes an OT report may be required (e.g., for a new client, to help advocate for more funding/support, care planning purposes). If a report is not indicated or required, we will generally send an email/letter of recommendation.

Yes

Funding (if applicable):*

Home Care Package (HCP)

Community Home Support Program (CHSP)

Funding:*

Are there funding limitations which may impact how we provide our service? We do our absolute best at providing a comprehensive service to our clients however if there are funding limitations it is important that we know so that we can adapt our approach accordingly. Please comment.

Package Level (if applicable):*

Home Care Package Level

My Aged Care Support Plan

Please advise if a My Aged Care support plan is available. If so, please include with referral via the file upload link at the bottom of this form.

Is there any additional information we should know?*

This may be related to safety concerns or certain people to contact on behalf of the client.

Best email address to send invoices to*

File

Max. file size: 500 MB.

HCP / Other Referral

Other Referrals