Driving Assessment & Training Referral

These forms 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

Download .pdf

Online referral form

Are you referring yourself or somebody else?(Required)

Myself

A client/Somebody else

Does the client have a current RMS Fitness to Drive medical report?(Required)

Please upload the RMS Fitness to Drive medical report(Required)

Drop files here or

Max. file size: 128 MB.

Referrer details

Referrer name(Required)

First Last

Referrer Organisation name

Referrer job title

Referrer email(Required)

Referrer phone

Consent obtained for referral?

Yes

Consent obtained to review file? (if internal referral)

Yes

Referrer address

Street Address City State / Province / Region ZIP / Postal Code

Client Details

Client name(Required)

First Last

Client email(Required)

Client phone

Client Address

Street Address City State / Province / Region ZIP / Postal Code

Client gender(Required)

Client Date of birth(Required)

Interpreter required

Yes

Preferred language

Do you identify as Aboriginal or Torres Strait Islander?(Required)

Licence Type

Licence number

CRN/Pension number

Medicare number

Funding Type(Required)

Government Allowance

What is the reason for your referral?(Required)

Services Requested

Primary Service Requested(Required)

Would you like to refer for a second service?(Required)

Second Service Requested(Required)

Would you like to refer for a third service?(Required)

Third Service Requested(Required)

Please provide any other relevant health information

Please list what weekdays the client is available

Initial assessment required?

Yes

Reassessment required?

Yes

Lessons required?

Yes

iCare/Insurance details

Insurer contact person name

First Last

Insurer contact person email

Insurer contact person phone

Do you have written approval?(Required)

Date of onset

Please attach approval

Drop files here or

Max. file size: 128 MB.

NDIS Details

Participant number

Plan start date

Plan end date

Does the participant have Capacity Building funds?

Does the participant have Social Participation funds?

Upload participant NDIS plan

Drop files here or

Max. file size: 128 MB.

Next of kin details

Next of kin name

First Last

Next of kin email

Next of kin phone

Next of kin address

Street Address City State / Province / Region ZIP / Postal Code

GP details

Would you like to add GP details to this referral?

GP name

Prefix First Last

GP clinic name

GP clinic phone

GP email

GP clinic address

Street Address City State / Province / Region ZIP / Postal Code

Support Coordinator/Case Manager details

Would you like to add a Support Coordinator or Case Manager to this referral?

Support Coordinator/Case Manager name

First Last

Organisation Name

Support Coordinator/Case Manager email

Support Coordinator/Case Manager phone

Plan Manager Details

Would you like to add a Plan Manager to this referral?

Plan Manager name

First Last

Organisation Name

Plan Manager email

Plan Manager phone

Other relevant contacts / Service providers for client

Would you like to add another relevant contact for this referral?

Other relevant contact name

First Last

Other relevant contact email

Other relevant contact phone

Who is the best contact on this form for appointments?

Client

Referrer (if not self-referral)

Case manager

Next of Kin

How did you hear about us?

Online advertisement

Social media

Google

Word of mouth

Radio

Publication (e.g newspaper)

Other

Hidden

Enquiry Type (CRM Field)

Hidden

Enquiry Sub-Type (CRM Field)

Hidden

Enquiry Stream (CRM Field)

Comments

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

Other referral forms

NDIS Referral

Download pdf

Online referral

icare Referral

Download pdf

Online referral

Sexuality Service Referral

Download pdf

Online referral

Ready to get started on your Royal Rehab LifeWorks journey?

Get in touch

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.

Driving Assessment & Training Referral

Online referral form

Referrer details

Client Details

Services Requested

iCare/Insurance details

NDIS Details

Next of kin details

GP details

Support Coordinator/Case Manager details

Plan Manager Details

Other relevant contacts / Service providers for client

Other referral forms

Contact us

Royal Rehab LifeWorks Locations

Other services

Book a site visit

Driving Assessment & Training Referral