Referral Form

This form can be used for self referrals or to refer someone else.

Please note: Privacy and confidentiality are of utmost importance to us. The referral information you provide will be used solely for the purpose of bookings. This information will not be retained for any other purpose and will only be accessed by authorised personnel in accordance with Royal Rehab’s privacy policy.

Online referral

Online referral form

Introduction

Participant details

Primary contact / carer / nominee details

Referral details

Risk Identification

Other details

Are you referring yourself?*

Do you/the participant have access to a current NDIS plan?

How did you hear about us?

How did you hear about us? (other)

Existing client?*

First name

Last name

Phone number*

Email*

What best describes your gender?

Post code

Specify gender

Address

Health / medical history

GP details (if known)

Contact first name

Contact last name

Contact phone (if different to participant)

Contact email (if different to participant)

Relationship to participant

Please specify "other" relationship

What are you referring for?

Funding amount or number of service hours required*

Please select Positive Behaviour Support required

Please specify the amount of funding (or hours) required for Specialist Behaviour Intervention

Please specify the amount of funding (or hours) required for Behaviour Management Plan

Please select Psychological Therapy required

Please select the primary Occupational Therapy required

Please specify "Other" therapy required

Please select the primary Speech Therapy required

Please specify "Other" therapy required

Does the client have a history of behaviour we should be aware of?

Relevant history of behaviour

Will any other people be present at the property during the appointment?

Relevant details of people present

Are there any pets at the property? (e.g. birds, cats, dogs, horses)

Relevant information about pets

Is there anything we need to know for access to the property?

Relevant property access details

Is there anything else we need to be aware of that may put you or us in any type of danger?

Relevant safety details

How is the Participant's NDIS plan managed?

Please specify 'Other' type of NDIS plan management

How urgently does the participant need support?

Contact person to organise sessions

Additional information or comments

Ready to get started on your Royal Rehab LifeWorks journey?

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In the spirit of reconciliation, Royal Rehab acknowledges the Traditional Custodians of Country throughout Australia and their connections to land, sea, and community. We pay our respects to their Elders past, present and future and we extend our respects to all Aboriginal and Torres Strait Island peoples.

Referral Form

Online referral form

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