Leadership Team Leadership Team NDIS Referral | Risk | Consent "*" indicates required fields Step 1 of 6 16% Referral Date DD dash MM dash YYYY Depending on your location and required therapy, we may be able to process your referral faster if you are happy to receive services via TeleHealth. Please select the TeleHealth option as well as the required services if this is suitable.Services required (select all that apply) Occupational Therapy Physiotherapy Exercise Physiology Speech Pathology Podiatry Dietetics Social Work Allied Health Assistance Region where services are required Sunshine Coast Moreton Bay North Brisbane Gympie area Fraser Coast Hervey Bay area Are you submitting this referral for yourself?Please selectYes, this referral is for meNo, this referral is for someone elseHiddenSection BreakReferrer detailsReferrer name First Name Last name Agency or organisation PhoneEmail* Enter Email Confirm Email Relationship to clientSupport CoordinatorPlan ManagerCarerLACFamily MemberOtherPlease describe Client/participant detailsClient/participant name First name Last name Date of birth DD slash MM slash YYYY GenderPlease selectFemaleMaleNon-binaryTransgenderIntersexPrefer not to sayAddress Street Address Address Line 2 City State Post Code Postal address Same as previous Address/PO Box Address Line 2 City State Post Code Home phoneMobileEmail* Enter Email Confirm Email Preferred contact methodPlease selectMobile - calls and text messageMobile - calls onlyMobile - text message onlyHome phoneEmailNo preferenceDoes the person being referred identify as Aboriginal or Torres Strait Islander? Aboriginal Torres Strait Islander Aboriginal and Torres Strait Islander No Prefer not to say Does the person being referred have any religious or cultural considerations we should be aware of? Yes (Please provide details below) No Please provide detailsDoes the person being referred require the assistance of an interpreter in order to access services? Yes (Please provide details below) No Please provide detailsReason for referral:Diagnosis group (tick all that apply)* We will ask for further information in the risk screening section Physical Sensory * Cognitive * Psychosocial * Primary diagnosis Amputation Autism Brain injury Cerebral Palsy Deaf Blind Genetic condition Hearing impairment Mental health (please specify below) Neurological Spinal injury Stroke Vision impairment Other (please specify below) Secondary diagnosis (if applicable) Amputation Autism Brain injury Cerebral Palsy Deaf Blind Genetic condition Hearing impairment Mental health (please specify below) Neurological Spinal injury Stroke Vision impairment Other (please specify below) Please provide further detailsPlease provide any further details of person's disability or other relevant health conditions NDIS informationDoes the person being referred already have an NDIS plan in place? Yes (please provide details below) No Plan detailsNDIS plan number How is the plan managed? Self managed Plan managed Agency (NDIA) managed * Plan start date DD slash MM slash YYYY Plan end date DD slash MM slash YYYY * Please note - as an agency-managed participant you are giving consent for Smart Solutions Rehab Group to claim payment for services provided through the Myplace Provider Portal. If you service agreement is not signed and returned prior to services commencing, Smart Solutions Rehab Group will not claim for any future services provided.Billing contact First name Last name Invoicing emailWhere would you like us to send invoices? Enter Email Confirm Email Would you like to provide us with a copy of the NDIS plan? Yes No Please upload the plan hereMax. file size: 100 MB.If no, please provide us with the NDIS plan goals so our clinician/s can plan accordingly.No NDIS plan in placePlease continue to the next page to arrange for a client services coordinator to call and discuss your requirements. Referral phone callWhen your referral is accepted a member of our Service Coordination team will contact you to organise a service agreement. Who should SSRG contact to discuss this referral and arrange/confirm appointments? Please contact person being referred Please contact the referrer Other (Please provide details below) Name* First Name Last name Relationship Support Coordinator Support Worker Legal guardian Next of kin Other support person Other Phone*Best day/s to call (please tick all that apply) Monday Tuesday Wednesday Thursday Friday Select AllBest time/s to call (please tick all that apply) 8:30am - 10:30am 10:30am - 12:30pm 12:30pm - 2:30pm 2:30pm - 4:00pm Select All Environmental risk screeningDoes the client consent to a home visit?Please selectYesNoAre all occupiers agreeable to a home visit?Please selectYesNoPlease provide names of anyone who will be present during the visit Please note that for our clinician's safety during your consultation we require that the premises be smoke free throughout the appointment, that all pets are restrained, and that visitors are kept to a minimum.* Please tick this box to confirm you can meet these safety requirements during your appointment. Please provide details of anything else the clinician needs to know before accessing the premisesFor example information about parking or access to the property Have there been any recent acts of abuse, aggression or violence on the premises? Yes No Please provide details Does anyone residing at the premises receive services from agencies such as Mental Health, Alcohol and Other Drugs? Yes No Please provide details Does anyone residing at the premises have any medical or psychiatric conditions of which our clinician should be aware? Yes No Please provide details Does anyone residing at the premises have a forensic history, a current criminal record, conviction, or supervision order? Yes No Please provide details Are there people who should NOT attend the premises while your clinician is present? Yes No Please provide details Does anyone residing at the premises have a current contagious condition (e.g., HIV, Hepatitis, Staph)? Yes No Please provide details Is anyone residing at the premises currently taking cytotoxic medications? (usually prescribed for cancer) Yes No Please provide details Comprehensive risk screeningDue to the diagnosis group selected, we will need to gather some additional information to better understand your circumstances. Once we receive this referral form, someone from our team will contact you during the time period you previously identified.Comprehensive risk screeningDue to the diagnosis group selected, we will need to gather some additional information about the participant to accurately assess the risk.SymptomsPlease identify any symptoms below that are relevant to the participant (tick all that apply): Excessive worry or fears Unusual or illogical thoughts Excessive anger or irritability Paranoia Unpredictable behaviours Auditory hallucinations (hearing voices) Visual hallucinations (seeing things) Sensory sensitivities Delusions Aggressive/violent behaviour Hoarding Gambling Thoughts of harm (self and others) Suicidal ideation Please provide further detailsPlease provide details of each symptom identified as well as duration and frequency of occurrence.Challenging behavioursPlease identify any behaviours which are relevant to the participant Hypersexuality Inappropriate touching Hiding Refusal Destruction of property Impulsivity Self-harm Stealing Hitting/biting/kicking Difficulty with personal space Screaming/swearing/yelling Please provide further detailsPlease provide details of each behaviour as well as the duration and frequency of occurrence.Current status of symptoms at current time: Acute - current episode of increased symptoms Chronic - symptoms well managed Fluctuating - symptoms/presentation changing frequently Please list any potential triggers the clinician should be aware of before engaging with the participant Please provide details of any ways that the clinician can support a positive interaction with the participant Service consentThe information below relates to the collection of the participant's information during the provision of services. All information is collected by Smart Solutions Rehab Group in accordance with our privacy policy which is available on request, or can be accessed via our website at ssrg.com.au/resources/privacy-policy/Please read the following information carefullySmart Solutions Rehab Group (the Provider) needs to collect information about you (the Client/Participant) for the primary purpose of quality service provision. To thoroughly assess, diagnose, and provide therapy we need to collect some personal information about you. The information will be used for: a) The administrative purpose of running the company b) Billing purposes - either directly or through an insurer or compensation agency c) Use within the company for collaboration among multiple practitioners in the interest of maximising service delivery d) Disclosure of information to your doctor/s, other health practitioner/s, or to professional trades people (e.g. for a home modification) to ensure best possible care for you (you can specify exactly who SSRG is authorised to request information from or release information to below) By providing consent you are agreeing to receive services from Smart Solutions Rehab Group and (where applicable) confirming that you are authorised to provide that consent on behalf of the participant named in the section 'client/participant details'. I have read the above information and consent to receiving allied health services from Smart Solutions Rehab Group (and, if applicable, I confirm that I am authorised to provide consent on behalf of the participant) .Consent for sharing informationThe information below relates to other health professionals or relevant stakeholders with whom we may need to share information in the provision of care. Please read through the information carefully and confirm who SSRG is able to request information from or release information to.I consent to SSRG requesting information relevant to my care from the following service providers:Please tick all that apply and provide further details below where needed Department of Communities, Child Safety and Disability Services Medical practitioners (e.g., GP, Paediatrician, Psychiatrist) Queensland Health Relevant non-government support services Family members Authorised representatives Other Please provide detailsYou do not have to provide this information right now, however we may request it at a later date. You can provide up to 8 names by clicking on the +NameRelationshipContact information Add RemoveI consent to SSRG releasing relevant information to the following service providers:Please tick all that apply and provide further details below where needed Department of Communities, Child Safety and Disability Services Medical practitioners (e.g., GP, Paediatrician, Psychiatrist) Queensland Health Relevant non-government support services Family members Authorised representatives Other Please provide detailsYou do not have to provide this information right now, however we may request it at a later date. You can provide up to 8 names.NameRelationshipContact information Add RemoveOther consentDo you consent to SSRG liaising with and disseminating relevant information to your current support co-ordinator or any future support coordinator? Yes No I don't have a support coordinator Do you consent to your SSRG clinician/s taking photographs of you or your home environment for the purposes of treatment, evaluation or training purposes? Yes No Name of person providing consent First Last Marketing informationHow did you hear about Smart Solutions Rehab Group? Google SSRG website Social media Friend/family Advertising material Care provider/GP Support coordinator/case manager Other Register for Updates Register for SSRG email notifications to receive valuable updates regarding our services. Date MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged. Δ
