Which Optimise Health and Wellness location *

InghamTownsville

Upload Health Plan

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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

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

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

YesNo

Functional Capacity Assessments / Plan Review Reporting *

YesNoUncertain

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

Support Coordinator *

YesNoUncertain

Does this person require home visits? *

YesNoUncertain

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

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