Support at Home Referral Click here for the NDIS Referral Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Consumer detailsDate of referral: *Name: *Phone number: *Email address: *Date of birth: *Gender *FemaleMaleTransgender/ Non Binary/ Gender DiversePrefer not to answerPreferred booking contact: *PhoneEmailContact via NOKContact via Case ManagerConsumer address: *HomeFacilityAddress: *Address Line 1CityState / Province / RegionPostal CodeNext of kin contact details / alternative contact person Name *Relationship: *Phone number: *Alternative number:Email address: risks: type Payment Referring person / company detailsName: *Email address: *Company: *Phone number: *Payment type: *Home Care Package (Support)PrivateSTRCCHSP providerMedicare CDM/EPCOther (please specify)Other: *Provider name: *Invoice contact name: *Coordinator’s name: *Email address for invoices: * Preferred appointment typeLocation: *Face to faceTelehealthNo preferenceTherapist gender: *FemaleMaleNo preferencePreferred language: *Is an interpreter required? *YesNoRegular unavailability (please provide days and times):Appointments, Care Workers, etc. Allied health service required Restorative Care Programs Restorative Care Program delivery options:Centre-basedIn-homeRemote telehealthPlease note, not all options are available for in-home or remote telehealth delivery.BeACTIV Dementia Program - 12 weeks 3 x 1hr Cognitive Stimulation Therapy + 1hr exercise per week + carer training (6 sessions)Health Joints Program - 12 weeksOption 1: 30 x 1hr exercise sessions (3 days per week x 10 weeks)Option 2: 24 x 1hr exercise sessions (2 days per week x 12 weeks)Option 3: 12 x 1hr exercise sessions (1 day per week x 12 weeks)Better Balance Program - 12 weeksOption 1: 30 x 1hr exercise sessions (3 days per week x 10 weeks)Option 2: 24 x 1hr exercise sessions (2 days per week x 12 weeks)Option 3: 12 x 1hr exercise sessions (1 day per week x 12 weeks)Breathe Better Program – 12 weeksOption 1: 24 x 1hr exercise sessions + education (2 days per week x 12 weeks)Option 2: 12 x 1hr group + 12 x 1hr telehealth exercise sessions + education (2 days per week x 12 weeks)Option 3: 12 x 1hr exercise essions + education (1 day per week x 12 weeks)Regain Control Program – 12 weeksOption 1: 20 x 1hr exercise sessions + education (2 days per week x 10 weeks)Option 2: 12 x 1hr exercise sessions + education (1 day per week x 12 weeks)Shake It Off Program – 12 weeksOption 1: 30 x 1hr exercise sessions (3 days per week x 10 weeks)Option 2: 24 x 1hr exercise sessions (2 days per week x 12 weeks)Option 3: 12 x 1hr exercise sessions (1 day per week x 12 weeks)Clinical allied health servicesOccupational therapy Occupational therapy - assessment of:Mobility and transfersFalls reviewEquipment reviewPowered mobility device or scooter assessmentHome safety assessmentHome environment and potential modificationsAssistive technologyActivities of daily living retrainingOtherMobility and transfers – area:Falls review – comment:Equipment review – comment:Powered mobility device or scooter assessment – describe:i.e. Currently driving? Has this person recently been reviewed by GP? When?Home safety assessment – area of concern:Home environment and potential modifications – describe:i.e. unable to access property (front, back, side), bathroom, toilet, bedroom, gardenActivities of daily living retraining – describe:Other – provide details:Physiotherapy Physiotherapy – assessment of:PainMobility and transfersStrength or range of motionFalls reviewPost hospitalisation or recent surgerySafety in the homeManual handling reviewOtherPain – body region:Mobility and transfers – area of concern:Strength or range of motion – body region:Falls review – comment:Post hospitalisation or recent surgery – describe:Safety in the home – area of home:Other – provide details:Dietetics Dietetics options:Dietary assessmentMeal planningLow or change to appetiteWeight managementNutrition support (oral supplements and enteral feeding)Chronic health managementDysphagia/texture modified diet planning (please refer in conjunction with a Speech Pathologist)OtherOther – provide details:Speech pathology Speech pathology options:Swallow/Eating/Drinking SupportMealtime Assessment PlanCommunication SupportVoice TherapyDysphagia/texture modified diet planning (please refer in conjunction with a Dietitian)OtherOther – provide details:Psychology Provide details:Social Work Provide details:Areas of concern: *Consumer primary goal: *Medical historyPrimary diagnosis: *Recent falls, surgery or risks: *Examples: Surgery in last 12 months, falls in the last 6 months Cognitive diagnosis: *Dementia, Alzheimer's or specific precautionsSpecific precautions:Examples: Mobility aids, 2 x assist, communicable disease Other relevant medical information: *Other informationOther relevant information:Other relevant documents: Drag & Drop Files, Choose Files to Upload Attach any relevant documentation, care plans and client risk assessment reports.SEND
