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HOME
ABOUT US
SERVICES
WORK WITH US
SUPPORT COORDINATORS
CONTACT

MAKE A REFERRAL

Referral Form

New or Returning Referral

Is this a returning referral?

Yes No Invalid Input

Returning referrals, please proceed to this form:

Returning Referrals

Participant Currently 18+

Is the participant over 18?

Yes No Invalid Input

Sorry, we may not be able to work with the participant, please let us know their current living location below.

Current Living Location

Where does the participant currently live?*

Townsville and Surrounds
Cairns and Surrounds
Rural and Remote Please let us know where the participant currently lives?

Sorry, we are unable to work with the participant.

Confirmation of Funding

Please confirm there is funding in the: Improved Daily Living (CB Daily Activity). An initial OT assessment, travel and identification of therapy/functional needs will take 5 hours. Please contact Propel Occupational Therapy for quotes for different services available (see list below).*

Yes (5 Hours minimum required)
Unsure / No. please let us know if there is funding in the sections above

If you are unsure of funding then please proceed to below form:

Unsure Funding Referrals

To assist us with ensuring we allocate the most suitable Occupational Therapist for participant, please provide reason for Occupational Therapy Assessment (tick all that apply).*

Skill building (e.g moving out of home, cooking, money skills, travel training, personal care skills)
Assistive Technology – low cost/low risk (e.g. shower chair, toilet seats, adapted kitchen aids).
Assistive Technology requiring prior approval from NDIS (high cost/high risk) e.g. scripted wheelchairs, shower commodes, bed, pressure cushions) . These items involve equipment trials, quotes and OT reports to NDIS.
Comprehensive Functional Assessment and Report (Care needs assessment)
Supported Independent Living / Specialist Disability Accommodation Assessment and Report.
Short Term Accommodation
Unsure
Other please provide reason for Occupational Therapy Assessment

Other

Invalid Input

Participant Information

First Name of Participant*

What is the First Name of the Participant?

Telephone of Participant

Please let us know the telephone number of the Participant

NDIS Participant Number if Applicable

Invalid Input

Last Name of Participant*

What is the Last Name of the Participant?

Particpant's Email

Please enter a valid Email Address

Date of Birth*

Please let us know the client's Date of Birth

Street Address*

Please let us know the Street Address of the participant.

City*

Invalid Input

State*

Please let us know what state the participant lives in

Postcode*

Please let us know the clients Postcode

What are the participant’s current concerns?*

please let us know the participants living arrangement

NDIS Plan Start Date:*

please let us know the NDIS Plan start date

NDIS Plan End Date:*

please let us know the NDIS Plan end date

List of Disabilities*

please provide a list of disabilities that the participant has

Do they have other conditions?*

Yes No please let us know if they have other medical history?

Other Conditions

Invalid Input

Support Person

First Name*

What is the support persons first name?

Phone Number*

What is the support person's phone number?

Last Name*

Please let us the support persons Last Name

Please enter a valid Email Address

Is the support person living with the participant*

Yes No please let us know if the Support person is living with the Participant

NDIS Coordinator

Are you a recurring NDIS Coordinator? then create an account with us and prefill some fields on your next submissions.

NDIS Coordinator Name

Please let us your First Name

Phone Number

Please let us your Phone Number

Please enter a valid Email Address

Preferred Contact

Please contact the...*

Participant Support Person Support Coordinator Please let us know the preferred contact

NDIS Funding Type

The NDIS funding type is...*

Self-Managed NDIA Managed Plan Managed please let us know the funding type

Plan Manager Organisation/Name*

Please let us know the Managers Name

Plan Manager's Email*

please let us know the Plan Manager's Email

Current NDIS Provider (Name/Type)

Invalid Input

Other Information

How Did You Hear About Us?*

please let us know how you found out about us

Other

Invalid Input

Name of Person Completing Form*

please let us know the name of the person completing this form

Confirm Email for Person Completing Form*

Please enter a valid Email Address

Please attach NDIS PLAN or EXTRACT of pages 1-5 showing participant’s profile and goals*

Please attach NDIS PLAN or EXTRACT of pages 1-5 showing participant’s profile and goals

(07) 4724 3684

2/137 Ingham Rd, West End
Townsville, QLD, Australia, 4810

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