OT referral form

SMS Occupational Therapy Referral Form

CLIENT DETAILS

First Name *

Last Name *

Preferred Name

Date of Birth *

Sex *

FemaleMale

Aboriginal or Torres Strait Islander Background

Neither Aboriginal nor Torres Strait IslanderAboriginalTorres Strait IslanderBoth Aboriginal and Torres Strait Islander

Preferred Language

CLIENT CONTACT DETAILS

Address

City / Suburb

Postcode

State

Home Phone

Mobile Phone

Preferred Contact Number

HomeMobile

Email Address

Who should we contact to make an appointment *

ClientNext of kin

Can we leave a message?

YesNo

NEXT OF KIN DETAILS

Next of Kin - Name

Next of Kin - Phone

Next of Kin - Email Address

REFERRER DETAILS

Name

Contact Number

Organisation/Address

Relationship to Client

REASON FOR REFERRAL

Main reason for referral *

General OT assessmentOT functional capacity assessmentOT home environmental assessmentFamily/carer education or support regarding cognitive impairment/dementiaFuture/accommodation planningDementia management adviceCOPE Program (Care of People with Dementia in their Environments)Capacity building/reablement therapyOther/none of the above

Please Note:

SMS OT services are cognition focused. We support clients with cognitive impairment or dementia. If your OT referral relates to issues arising from a predominantly physical condition/impairment (e.g. you require specialised assistive technology for high physical needs) we may not be the best service for you. Please call us if you wish to discuss.

The Care of People in their Environments Program (COPE) is an evidence-based OT and nursing program for people with dementia and their carers. Running over 8-10 sessions, COPE supports both the patient and the carer in managing day-to-day activities at home. Sessions can be completed either at home or the SMS clinic and will be scheduled to suits your needs. For more information about this program see: https://copeprogram.com.au.

Please Note:

We advise on environmental modifications to optimise performance due to cognitive impairment or dementia, but we do not address major structural/home modifications.

Further details and any OT goals *

RELEVANT BACKGROUND INFORMATION / MEDICAL HISTORY

Please summarise any relevant background information & medical history *

FUNDING SOURCE

I confirm there is funding for OT in the current NDIS plan *

YesNo

NDIS Participant Number *

NDIS Plan Dates *

NDIS Invoices to *

Support Coordinator Name *

Support Coordinator Contact Number *

My GP has referred me for OT via an ECP/Chronic Disease Management Plan *

YesNo

Please Note: SMS charges a gap fee for Medicare funded OT appointments. Please ensure all necessary paperwork has been completed by your GP prior to your appointment.

Medicare funding for OT can is only available for patients referred via their GP with an ECP/Chronic Disease Management Plan. Please discuss referral with your GP.

Name as appears on Medicare Card *

Medicare Number *

Home Care Package Provider *

Case Manager Name & Contact Number *

If Other please provide details *

SIGNATURE

I confirm that the information I have provided above is true, complete and accurate. *

Client/Nominated Representative Signature

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