Make a Referral - Ontime Healthcare

"*" indicates required fields

PARTICIPANT’S DETAILS

Participant Name*

Participant Preferred Name

Preferred pronoun

NDIS Participant's Number*

Participant Date of Birth*

NDIS recognised diagnosis**

Street Address*

Suburb*

State*

Post Code*

Participant’s Phone Number

Participant Email*

As the Participant are you, or is the Participant, of Aboriginal and/or Torres Strait Islander origin? **

REFERRING PARTY

Referring Party’s Name (typically you)*

Primary Relationship to Participant*

Other Relationship to Participant

Referring Party’s Phone Number*

Referring Party’s Email Address*

Other Relevant Contacts

SERVICE REQUEST

Altius Group offers a range of assessments and therapies across QLD, NSW, ACT, VIC, NT, TAS, SA and WA (via In-Person and Video Telehealth) by the following Health Professionals:

Exercise Physiologists
Occupational Therapists
Physiotherapy
Psychologists
Speech Pathology
Therapy Assistants (Occupational Therapy)

Please Note: Altius Group is able to provide these services to participants aged 7 years and older; We are not able to offer Positive Behaviour Support Services to any participant.

Plan Start Date*

Plan End Date*

Is the Referral Urgent?*

If the referral is urgent, please explain why

On what date is the completed service required?

First Type of Health Professional required*

Service Required from First Professional*

Would you like a follow up consultation post report completion to review recommendations and plan any required ongoing services*

Funded Hours Available for this Service*

Second Type of Health Professional required (optional)

Service Required from Second Professional (optional)

Funded Hours Available for this Service

What Other services do you require?

Is Telehealth (via video) an option for the Participant?*

Do you have a preference for the gender of your consultant?*

SERVICE AGREEMENT

Is the Service Agreement to be sent to the Participant or their Representative for signature?*

Current Funding Management*

Email address for invoicing

Is Third Party approval required?*

Email address for the Third Party for approval

What are you hoping to achieve from the referral?

Do you have any additional comments?

Please provide the name of your preferred Altius Group NDIS consultant, if known

Upload Goals Document (optional) If possible, please upload a copy of the Participant’s Goals document.

Max. file size: 16 MB.

This document may be required to fulfill service delivery, so if not provided here we may request it following your referral.

How did you hear about us?*

Would you like to know more about our Disability Employment Service (DES)?

MANDATORY RISK ASSESSMENT QUESTIONNAIRE

Are there any communication supports in place or required?*

Please specify communication supports

Is an interpreter required?*

Please specify interpreter requirements

Does the participant live alone?*

Does the participant live in a remote area?*

Are the any concerns around the participants home environment we should be aware of?*

Please specify the concerns

Can the participant potentially become agitated or aggressive?*

Please specify

What are the known triggers causing the behaviours of concern?*

Is there a current positive behaviour plan in place?*

Please provide a copy of the behaviour plan by uploading it here

Max. file size: 16 MB.

Will an authorised person, guardian, support worker or other nominee be present during assessments and face to face interactions with the participant?*

Please specify details of attendance

Has the participant been convicted of a criminal offence in the past?*

Are there any legal orders currently in place?*

Are there any other considerations we should be aware of?*

Select the options that apply (you may select more than one)

None

Animals present

Easily fatigued

Needs assessment away from home environment

Other house members have behaviours of concern

Weapons present

Other

Other: Please Specify

Are there any cultural considerations to be aware of?

This field is for validation purposes and should be left unchanged.