Third party referralParticipant self-presentedDoctor Referral

Which Optimise Health and Wellness location *

InghamTownsvillePalm Island Visits

Upload Health Plan *

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Extra Upload for Doctor Referral

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Participant Registration Form Upload

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Participant Consent Form Upload

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Participant Service Agreement Upload

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Any relevant notes

Booking Information

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 *

Address

Street address

City

State

Postcode

Does the Participant 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

NDIS Information

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

YesNo

NDIS Number *

Plan Start date *

Plan End\Review date *

Plan Management *

Agency ManagedPlan ManagedSelf-Managed

Plan Manager

Plan Manager Contact Number

Do you have a Support Coordinator?

YesNo

Support Coordinator Name

Support Coordinator contact number

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 *

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

Details *

Nursing Care - Delivery of Health Supports *

YesNoUncertain

Details *

Plan Management *

YesNoUncertain

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.

Reception of Referral

I have received and acknowledge referral *

I have set up Participant in Gensolve *

I have all relevant forms

Notes regarding Referral

Is the Information provided complete and accurate *

YesNo

Were there any changes to the information?

YesNo

Notes

Uploaded Notes

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Update details in Gensolve and complete Service Bookings

I have updated Participant details in Gensolve *

I have completed the Service Booking

Upload Service Agreement

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Name of staff member *

Date *

Is there capacity to accept the Participant? *

AcceptPut on waiting listDecline

Reasons for declining/putting on wait list *

Clinician delegated to Participant *

Email of Clinician *

Notes

Capacity to take Participant of Waitlist

We have capacity to take on Participant *

Participant's details are up-to-date and accurate

Accept Participant

Accept Participant

Notes

Accept Participant

I accept the client *

Notes regarding Participant

Book Appointment

I have booked an appointment to see the client *

Date and Time of Clinician appointment *

Workflow complete

Workflow complete *

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