Service Pathway *

NDISFee for service (Private)DVAMedicare

Which Optimise Health and Wellness location *

InghamTownsville

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Extra Upload for Doctor Referral

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Any relevant uploads

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Any other relevant uploads

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Participant Details

Who is completing this referral?

Client or their representativeReferrer

Aged Care ID number

Referrer Full Name *

Referrer Organisation *

Referrer Email *

Referrer Contact Number *

Date of Referral *

Participant First Name *

Participant Last Name *

Participant Date of Birth *

Participant Contact Number *

Does the Participant/Participant Representative have a mobile phone number? *

YesNoAs above

Mobile Phone Number

SMS Appointment Reminders

YesNo

Participant Email address

Participant Gender

MaleFemaleOther

Aboriginal or Torres Strait Islander - Optional

YesNo

Any other Ethnic Origin? (E.g. Italian, English etc.) - Optional

YesNo

Please state Ethnic Origin/s

Is an Interpreter Required (Incl. Auslan)?

YesNo

What type of Interpreter is required? (e.g. Chinese, Spanish, Auslan etc.)

Address *

Street address *

City *

State *

Postcode *

Postal Address is different to Street Address

Postal Address *

Street address\PO Box *

City *

State *

Postcode *

Next of Kin (Full Name) *

Relationship *

Contact Number for Next of Kin *

Is the Participant a child or do they have a Carer/Guardian? *

YesNoPublic Guardian

First name of Carer/Guardian *

Last name of Carer/Guardian *

Contact Number of Carer/Guardian *

First Name of Public Guardian *

Last name of Public Guardian *

Contact Number of Public Guardian

Does Participant have a Public Trust

YesNo

First Name of Public Trustee

Last Name of Public Trustee

Contact details of Public Trustee

Best Contact Email Address for Correspondence *It is important that you ensure that the email address is accurate

Preferred Medical Centre

Do you have a preferred GP? *

YesNo

Preferred GP

Do you have any of the following?

Medicare CardCentrelink Customer Reference Number (CRN)Health Care CardDVA

Medicare Number *

Ref Number *

Expiry Date *

Centrelink Customer Reference Number (CRN)

Health Care Card Number

Expiry Date

DVA Card Number *

DVA Card Type *

WhiteGold

Expiry Date *

Do you have a disability you wish to tell us about? *

YesNo

Details:

Does the Participant have, or have they had, an NDIS plan? *

YesNoPending

NDIS Information

NDIS Number *

Plan Start date

Plan End\Review date

Plan Management *

Agency ManagedPlan ManagedSelf-ManagedPending

Plan Manager

Plan Manager Contact Number

Do you have a Support Coordinator?

YesNo

Support Coordinator Name

Support Coordinator contact number

Support Coordinator Email *

NDIS plan able to be provided *

YesNo

Reason *

NDIS Plan *

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Participant Support Details

Primary Diagnosis (What condition does the Participant have?) *

Are there any other relevant conditions?

YesNo

Relevant Conditions *

What services will the Participant require?

Assistive Technology *

YesNoUncertain

Details

Home Modifications *

YesNoUncertain

MajorMinor

Details

Ongoing Therapy/Group Therapy *

YesNoUncertain

Details

Occupational Therapy *

YesNoUncertain

Details

Is the Participant happy to engage with a Therapy Assistant? *

YesNo

Functional Capacity Assessments / Plan Review Reporting *

YesNoUncertain

If referred by GP and using Medicare it will entail an out of pocket expense (between approx - $690 and $930 depending on Medicare visits available)

Details

Driving Assessment *

YesNoUncertain

Details

Mental Health *

YesNoUncertain

Details

Personal Training/Excercise Physiologist (Currently only in Ingham) *

YesNoUncertain

Details

Dietetics Assessment *

YesNoUncertain

Current Medications and Supplements

What would you like help with?

What Core Support Services does the participant require from Optimise Health and Wellness?

Support Workers - Assistance with self-care activities/access to community, social and recreational activities/personal domestic activities *

YesNoUncertain

This is currently available for Ingham and surrounds only

Details

Nursing Care - Delivery of Health Supports *

YesNoUncertain

Details

Plan Management

Our plan management services are now available through Optimal Plan Management

Would you like to engage with Optimal Plan Management services?

YesNo

Does this person require home visits? *

YesNoUncertain

A Home Visiting Risk Assessment Form MUST BE COMPLETED IF PRACTITIONER WILL BE ATTENDING THE PARTICIPANTS RESIDENCE.

Any other comments:

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